0:00:00.3 Kurt Baker: What does it take to revolutionize geriatric care and bring quality medical services directly to older adults? Meet Dr. Arun Rao, a fellowship trained and board certified geriatrician with over 20 years of experience as a founder and CEO of Geriatrics Planning and Solutions Inc. Dr. Rao is dedicated to providing expert medical care through a direct pay house call service, ensuring seniors receive the attention they need in the comfort of their own homes. Leadership roles at institutions like Weill Cornell Medical College and Penn Medicine Princeton Health. He has spent his career improving geriatric health care across hospitals, nursing facilities and assisted living communities. Today he joins us to share his expertise, insights and passion for redefining geriatric care. Please welcome Dr. Arun S. Rao. That’s awesome.
0:01:03.4 Dr. Arun Rao: Thanks.
0:01:05.6 Kurt Baker: Yeah, this is really cool. I mean we were talking at a chamber event and myself just a couple years ago, I had had like traditional “medical care” right? But we ended up going to a concierge doctor system which is kind of a blend, I guess. Some direct pay, some not. So that was interesting. But I’ve become kind of a big advocate only because I’ve noticed a difference. Like the doctor spends like an hour with me instead of like five to 10 minutes. And they kind of get to know you a lot better. And I thought it was very interesting. We were talking, I hadn’t really heard of it in this sector, so to speak. So can you tell a little bit about maybe what sparked your interest in this and why you shifted from like maybe a more traditional, I’ll call it model to something that’s more of a direct pay model? Can we kind of start with your…
0:01:50.8 Dr. Arun Rao: So as many listeners and people might know, this whole concierge physician movement has been picking up steam. And I’ve actually been in practice in geriatrics for it’s going to be 25 years now and had practiced in pretty much every venue of care where you might see an older adult, from hospital to nursing facility to assisted living to home to the traditional kind of ambulatory care practice in the office. And I enjoy taking care of older adults in that setting. But what I really realized over the past two to three years was that a lot of older adults and their families and caregivers were not getting their questions answered. And I think it’s a reflection of where our healthcare system is these days. It’s very fragmented, it’s discoordinated. Doctors are under a lot of pressure to see a significant volume of patients which impacts time adversely. And then once time is impacted, especially in an intimate relationship, like a physician-patient relationship. That’s where you get the traditional expectations of medicine kind of going out the window, like my doctor really knows me or I understands me, or has time to kind of talk and explain things to me.
0:03:11.0 Dr. Arun Rao: And so what I realized was that this was really hard to meet as a traditional practitioner. And it kind of forced me to search within myself to kind of say, what did I go into geriatrics for? Number one, I enjoy taking care of older adults from a medical perspective. Number two, it also goes into what the definition of a doctor is. A doctor comes from Latin docere, which is to teach. And so I wasn’t kind of feeling, I felt like I wasn’t able to sit down and educate my patients and families about their health conditions, about their functional status, about cognitive changes, about what’s kind of “coming down the pike” and how to be prepared for that. And so I said I have to figure out something outside the system. And so started scratching the surface of Google, which is everybody’s encyclopedia these days, and kind of looking around and I came to realize that maybe what I need to do is kind of go out the traditional setting of healthcare and do something similar to a concierge practice. And so I decided to voluntarily opt out of Medicare. And I can explain a little bit later as to why I had to do that to do what I’m doing.
0:04:27.2 Dr. Arun Rao: And started a direct pay practice model where I do 100% house calls, I have no office, my office is my car and my laptop and I go to patients houses and I’m really there to do what I call helping you make sense of medical complexity, put your medical problems together, assess your functional status, assess your cognitive status and really assess you as a person and what your priorities and goals for care are at this juncture. And how can we tailor the medical plan of care to fit what’s important to you as well as serve as kind of the bridge to coordinate communication and care between multiple doctors and prescriptions and the whole kind of spider web that older adults quite often face, especially older adults with chronic medical conditions.
0:05:20.6 Kurt Baker: No, it’s very interesting and you mentioned there that 100% of your service is going to the patient. And I was part of a community organization several years ago we did a survey, at least in Mercer county. And one of the top three issues in the county as far as health went was older people have difficulty getting to a doctor, period. So if you’re in a situation where you’re not really able to drive or things like that that’s another barrier where you can’t even. Even when you have the care taken care of, once you get there, you just physically can’t get to the doctor. Which frankly, hadn’t even occurred to me until the service came back. Because, I mean, I’m so used to. I get in my car, I go somewhere, it’s not a big deal, right? You’re like, wow. And you don’t really think that that’s actually a fairly major issue for our older population. And now you kind of flipped it back to a traditional. I’m thinking, I’ve got this picture of you, like in the 1800s, all of a sudden, you know, where the doctor came to the house and took care of the patients.
0:06:13.7 Kurt Baker: And the other part I didn’t know that is to teach is brilliant because that makes a lot of sense because we are our primary care physicians, so to speak. I mean, obviously we need a doctor, but ultimately we have to take care of ourselves. And it’s hard to do that without the proper advice as far as individualized, because we’re all a little bit different. I mean, even with the same family, like, things that I do might be slightly different than my daughter, my wife, etcetera, etcetera, etcetera, because we’re all different and the things that we need. So I think it’s great what you’re doing. So what did you see initially when you… Because that’s a big move. I mean, going from… I mean, I know some doctors that kind of like work, work their way over. Like, maybe they held this practice for a while and then they opened like another one or they did some blend or I mean, they kind of… It’s kind of hard to give up, like, boom, overnight, flip everything over. So how did you kind of transition over from what you were doing before? You’ve been doing a long time and then just say, oh, okay, here’s what I’m going to do now. I’m just kind of curious how that transition might happen for a doctor.
0:07:12.7 Dr. Arun Rao: So for being kind of a type A person, a lot of of planning, a lot of research ahead of time. I mean, I launched this practice about a year and a half ago, but realistically, I was probably thinking and planning about it for two to three years now. And when I really look back at it, I think that I tapped into something that I’ve wanted to do probably all my life. And in terms of the planning, I think a big part of the planning was really communication with my wife also. She’s also a physician so we’re both physicians and we have two kids and the usual kind of hamster wheel spinning of day-to-day life. And we had to figure out, is this going to be something that’s feasible for us at this stage of our careers and this stage of our lives. And so we had to have a lot of kind of discussions as to what this is going to look like because I’m not going to be kind of a traditional, salary, bi-weekly salary, benefits, the whole thing. I’m going to be doing something on my own.
0:08:19.8 Dr. Arun Rao: And I was never an entrepreneur before. And no one teaches you about entrepreneurship in medical school.
0:08:24.4 Kurt Baker: Welcome to the fun.
0:08:26.8 Dr. Arun Rao: So there was a lot of learning about the whole business aspect of it. What do you need to do to establish and everything like that. And so I think it was really a lot of planning, a lot of research, a lot of tapping into friends and colleagues who are entrepreneurs as to what do you need to do. There is also a lot of what I would say is almost groundbreaking because kind of what I’m doing does not exist very much elsewhere.
0:08:50.9 Kurt Baker: That was my next question. Is there like an association? Because everybody has an association. So I mean, I’m dealing with a direct pay pediatrician myself on some stuff. And she says the industry’s only been around like three to five years or something. I was shocked because I thought it was cool when I heard about it. And then when I heard it was only been around that long, I was like, wow. Because the other concierge has been around for quite a while for adults.
0:09:10.2 Dr. Arun Rao: Right.
0:09:11.6 Kurt Baker: And so how long? I’m just curious, like, how long has it been around? And do you have other peers, so to speak, or other people you can now have conversations with? Because that’s really where you can kind of mastermind, say, hey, here’s what I’m doing and here’s how it’s working. Here’s the things that people are seeing and make adjustments to your business plan. It’s always a lot easier to do it if you have other people giving you feedback from what they’re seeing as well.
0:09:32.3 Dr. Arun Rao: Right. So I looked hard and honestly I felt like I was in a field with the crickets chirping. Okay. Because I mean, I’ve trained at academic institutions, so I was at the University of Michigan, which has a huge geriatrics program. I then started my career at Weill Cornell, which also has a huge geriatrics program in New York City. And I tapped a lot of my colleagues and peers and said, hey, have you heard of anybody who do that. And honestly, the answer was no, there aren’t that many geriatricians. And I think at the end of the day, I came across two other people in this country.
0:10:10.5 Kurt Baker: Wow.
0:10:11.3 Dr. Arun Rao: Who were doing something similar to what I wanted to do. There’s a woman who’s a geriatrician out in the Bay Area in California who had started this. And I kind of reached out to her and she gave me some pointers in her perspective on what this was like. And she has slowly changed her practice because I think she really wanted to get into the education aspect of it and create kind of a blog site for caregivers. So she has kind of phased out her clinical practice aspect of it and turned it more into an education. And then there’s one other woman who also practices, I think, in Utah and California similarly. She doesn’t do all house calls. I think she also has an office practice. So not a lot of people out there doing kind of what I’m doing. And so a classic example of this was, naturally, as a physician, when you start a practice, you need to obtain malpractice insurance. And so in speaking with insurance brokers and trying to figure out who’s going to be covering me, I would say, like, 95% to 99% of the insurance brokers had no idea what I was doing or they had nothing to compare me to.
0:11:20.7 Kurt Baker: How do you underwrite the risk if there’s nothing else to see? Right.
0:11:23.2 Dr. Arun Rao: Yeah. And so learning the whole kind of malpractice insurance industry and what kind of plans are out there for providers who want to do what I want to do, I think I’m still kind of breaking a little bit of ground with the insurance covers about this whole thing. So I think it’s fun in the sense that I’m kind of learning a lot and I’m hopefully paving the way for other people who want to do this. But it’s also daunting.
0:11:51.4 Kurt Baker: Yeah, no, I’m getting you. Basically, it sounds like you’re going to be in a leadership position. Right. It sounds like to me. Because you’re literally cutting through the jungle first. Yeah, that’s really awesome. So we’ll… Yeah, just let me think about that for a second.
0:12:07.2 Dr. Arun Rao: Sure, Absolutely.
0:12:08.2 Kurt Baker: Absolutely.
0:12:09.1 Dr. Arun Rao: And it… Oh, sorry.
0:12:12.5 Kurt Baker: Okay. Yeah. So now that you’re officially a leader, because you’re the first one to the field, so to speak, I’m seeing a couple things for you here, actually. I mean, I’m not advising you, obviously, but it’s kind of like. Because one is, if you’ve got other people that might have a similar career that you had. Maybe there’s others that are thinking about this but haven’t actually pulled the trigger, so to speak. They’re like you, they have to take two or three years to research. Or maybe they said, I don’t really feel like doing it. I’ll just keep doing what I’m doing. It seems to be working, I’m done. But they might be much happier if they did shift, because I know that any doctor I’ve talked to personally that’s made that shift, it was a little nerve wracking doing it. And they were a little concerned because you’re giving up hundreds of patients for a relatively small number for higher cost per they’re paying you directly. And it’s a whole different business model. And when you shift business models from something that does function, maybe you’re working yourself really hard, but it actually works to something that’s a little like, I don’t know if it’s going to work or how many people are going to want to pay me for this.
0:13:09.3 Kurt Baker: Right. You just don’t know how it’s going to work out. It would be good. So I guess my question is what would somebody’s job be now that might have, like what you were doing before that might consider it? And how big is that group? I guess I’m asking, is there hundreds, thousands? I mean, is that a fairly small group already that you came from?
0:13:31.5 Dr. Arun Rao: Yeah. So, I mean, in terms of… So we can answer this a couple ways. So in terms of demographics, if you want to think about it, the United States currently has anywhere between 55 and 60 million people over the age of 65. They fall into the traditional geriatrics kind of catchment. There’s, only about 7,100 to 7,300 board certified geriatricians in this country.
0:13:57.1 Kurt Baker: That’s not a good ratio.
0:13:58.5 Dr. Arun Rao: So they’re estimating that probably between now and the next five to seven years, it’s going to be one geriatrician for every 10,000 people over the age of 65 in this country. One geriatrician, realistically, in a traditional practice model can probably take care of about 500 to 700 patients.
0:14:19.2 Kurt Baker: Okay, wow, that still sounds like a lot to me but…
0:14:21.5 Dr. Arun Rao: So there’s an issue that the American Geriatric Society is working on in terms of how do we build the pipeline to kind of build more geriatricians in the workforce. And there’s a lot of reasons, and that’s probably a whole other show as to why people don’t choose this. So there aren’t that many people kind of doing what I’m doing. And I think the people who would consider something like this, I think a lot of physicians probably have or are considering this because of burnout.
0:14:50.3 Kurt Baker: Yeah, that’s…
0:14:51.6 Dr. Arun Rao: The traditional practice model right now is devaluing what a physician’s worth is.
0:14:56.4 Kurt Baker: And I hear price compression all the time and reimbursement and things like that are getting so brutal that they have to keep on taking on more and more patients just to maintain their standard of living, which is…
0:15:04.6 Dr. Arun Rao: Right. It’s basically volume and turnover and there’s huge administrative burden. You know, a physician might see a patient, might have a patient practice day of, you know, from 8 o’clock in the morning till 5 in the afternoon, maybe with a one hour lunch break. That’s when they’re seeing patients and making the decisions, as well as talking to other doctors and hospitals and stuff like that about things that are going on. They get home at 6:00 in the evening, they probably still have at least another three to four hours of documentation and after work to take care of that is not paid.
0:15:39.5 Kurt Baker: Right.
0:15:41.2 Dr. Arun Rao: And you can imagine how frustrating this can be for a physician, especially young physicians who are coming out of the medical school training process with a significant amount of debt at a time in their lives when they might be starting families, buying houses, etcetera. And so it’s hard. It’s a really hard lifestyle. I mean, I talk about my wife. My wife’s been in practice for about 20 years as well, and she loves what she does. But there’s definitely an element of kind of burnout in that she has a full day of practice and then has to come home and answer phone calls and take care of paperwork and write her notes. And so I think that’s the group that periodically will kind of turn this idea over and out of that group. I don’t know that there are many that will jump and do something like this, partly because it’s unchartered territory.
0:16:32.9 Kurt Baker: Yeah. I think they need a framework or a path to transition because that’s what I’ve heard from other people have actually done that change from the traditional cons here. It’s like, yeah, that sounds good over there, but I’m not sure how to get from where I am now to there. And I guess that’s what I was kind of touching on is that perhaps if you were sharing your journey about how did you do this transition and how can you minimize the risk to maybe another physician that might be thinking about it. Because from my perspective as a consumer, I’m like, I don’t want that person to burn out and quit and retire. I want that person to go to a format that actually, they can function long term and actually enjoy their job. I mean, we have a vet that we go to now and he just, he’s retired like three or four times, but he likes to do operations. So he comes in one or two days a week, does operations. That’s it, he goes home. But, but that’s because he likes that part. Now he’s working two days a week instead of six that he might have been working before.
0:17:21.9 Kurt Baker: And that was all purely quality of life for him. So my concern is we keep seeing these stats about how we’re losing our doctors and they’re gonna retire and they’re not coming in fast enough. So anyway, that’s the reason for kind of wondering how that might work out.
0:17:36.8 Dr. Arun Rao: So I think it goes back to the whole conversation and communication thing. You have to sit down and figure out what are your life circumstances, what are your needs and is this something that you can do? Because the first, I mean, I’m still in the first year and a half. You know, the first several years until you establish your name and get your foot off the ground and run, it’s not guaranteed income. And many times if you’re going out on your own, it’s not. Benefits are not there. So health insurance, you know, life insurance, disability, all that kind of stuff. So you have to factor all that kind of stuff in. And that’s probably what holds back a lot of people. And I’m not going to say that that’s not an unrealistic holdback. That’s real. That’s life. Right.
0:18:17.9 Kurt Baker: One thing just dawned on me. You’re dealing with an older generation, so you’ve got mortality issues going on here as well. I would think…
0:18:25.7 Dr. Arun Rao: From a patient…
0:18:28.6 Kurt Baker: As opposed to general. If I’m working on a 30 year old, pretty good chance I’m having them for 20, 30 years. I’m working on somebody who’s 80. I’m not sure how. I mean, I’m bringing this patient in, that’s great. But I don’t know what their longevity is necessarily. Right. I mean, it’s might be shorter than other doctors, I guess it’s the only thing I’m pointing out is that there’s another risk that I hadn’t even thought about until you started talking just now.
0:18:45.6 Dr. Arun Rao: Which is something that I’m starting to scratch the surface of right now is what is the sustainability in terms of practice? Because like you said, especially most of my patients are in their 80s, 90s, that’s what I really enjoy taking care of. But as you said, they might be frail or they might have certain conditions that are going to limit their longevity. And so I have to sit down and think I’m going to bring this patient on board my panel. How long are they going to be with me and what do I need to do to kind of keep a patient panel going, which is much harder in the older age population than like you said, if you have a panel of patients that are in their 40s, 50s and 60s, they’re going to be there for a while.
0:19:25.8 Kurt Baker: So are a lot of these in some type of residential or long term care or assisted living kind of situations that you’re dealing with? Are they actually physically still in their house generally? Or I mean, what do you, what do you see now? What do you see the vision? Because I can see if somebody goes to an assisted living example, they’re still functioning, they’re still pretty, but they may not like they can drive it. They may just like the convenience of it. It’s almost like giving in a really nice condo association kind of deal. Is there an opportunity here where if you talk to some of these places that are already providing extra care to these people and if they like it? Because I know people that really like the assisted living. I know a fellow advisor who’s perfect health. He just likes it because he likes the lifestyle. He’s like, take care of all this stuff for me. I don’t worry about it.
0:20:08.3 Dr. Arun Rao: It’s like, so my practice is focused pretty much 97% on house. So I go into patients houses. I’ll go into what’s called independent living communities, which are basically communities built up for older adults. But they don’t have any central kind of physician or health care services. I can also go into like your active adult communities, like the 55 and over communities and do that. I tend not to go into assisted living or skilled nursing facilities for delivery of what I call primary care or medical care. I can go in there as a health advocate or a health educator to help patients and families kind of understand what’s going on. But I don’t provide direct care there primarily because an assisted living facility or a skilled nursing facility will have a physician or a group of physicians.
0:20:57.1 Kurt Baker: Well, that’s a much higher level of care. I’m thinking of the steps beforehand. Like basically what you Just described.
0:21:03.2 Dr. Arun Rao: So kind of before they get into those sites of care.
0:21:07.5 Kurt Baker: Okay, yeah, I’m just thinking there’s a lot of people around here. I mean, where we live, people move from up North Jersey down to this area. And you know, you’ve got areas that are, you know, literally the town is pretty much the 55 and older. These different active communities as you speak of, and they generally have the means to have this kind of care if they knew about it. See, I didn’t really even as advisor years ago, I was like, I started knowing about it, I started learning about it, and then you start saying, oh, and then you start hearing about other people that are using it it. And then you realize it’s all a personal decision, obviously. But then you realize, well, this actually makes some sense for us to do this because I’m a big believer in preventative care. And let’s work on these things early in the cycle as opposed to the reactive traditional kind of thing like, oh, you’ve got a diagnosis, now we have to treat it. I would say, well, how about if we get to the point where we don’t have the diagnosis in the first place, if possible. So anyway, that’s just…
0:22:00.5 Dr. Arun Rao: Yeah. So I think in terms of the communities around here, so if you think about it, we live in Mercer county, just across the border, so to speak, is Monroe. And Monroe, traditionally, until recently, I’m not sure about the current statistics, Monroe had the highest density of older adult communities in the country. And it’s probably changed now. But yeah, definitely there’s a population here that can need it. The question is, who wants to make a decision to go to a private physician? And honestly, I have to leave that to the patients and families. Does this make sense for you? Is this what you want? If I go to most older adults themselves directly, they’re going to say, well, I’ve been paying into Medicare for 50, 60 years. Why should I pay out of pocket for a physician? And the question is, are you happy with your current physician and providers? Are you getting the information you need? Are you getting the time that you need? And if you feel you are, then that’s fine. I don’t want to mess with happiness.
0:22:57.6 Kurt Baker: Yeah, absolutely. I definitely 100% agree. So speaking of Medicare, explain to me or us how you had to basically, I don’t know what you call it, but disenroll I’ll call as far as using being reimbursed by them. So you said there was an issue with the Medicare system for you trying to do this model, what happened and why did you elect that position?
0:23:21.7 Dr. Arun Rao: So as everyone knows, Medicare is the government health insurance for adults over the age of 65 or those with disabilities. And some patients on hemodialysis can kind of get onto Medicare a little bit earlier. Medicare kind of says that a physician cannot charge privately for services that Medicare itself would cover. And so a lot of work that I do under geriatrics, which could be kind of primary care or counseling about goals of care and advanced care planning or palliative care and things like that, ordering, you know, things like are covered under Medicare. So technically, if I was still under Medicare, I would not be able to charge people privately for that. So what I had to do was basically write to Medicare. Medicare has regional kind of administrative offices. So I wrote to our region’s Medicare office and said, hey, I’m a physician, I would like to opt out of Medicare voluntarily. And that’s it. And Medicare kind of reviews it and they say, okay, you’re opted out. You’re opted out for two years at a time. And if you don’t write them a letter at the end of the two years saying that you intend to stay opted out, they kind of pull you back in. So it’s kind of like the mafia. You can’t get out.
0:24:41.0 Kurt Baker: They want you in the system. They want you in the system. So I guess the next question is, okay, if I’m a patient and I see where I’m getting the front end high touch care from you, but if I have to go to the hospital, have an operation or something like that, that doctor could be under Medicare. If it’s not necessary, it doesn’t necessarily mean I can’t use Medicare as a patient. It just means when it’s with a relationship with you, there’s not a Medicare is not going to pay for that. You have to pay for it direct. So that’s why they have the direct pay aspect. But if there’s some issue where I have to be referred to a doctor, the likelihood is, of course, in this case that they would be a Medicare approved doctor and that would… Then it would kick in, correct?
0:25:19.8 Dr. Arun Rao: Yeah. So remember, that’s a great question and it’s a great point and something that gets asked all the time. The patient has not opted out of Medicare. The patient’s still on Medicare. My services, my direct services, my coming to the house, doing the history, the physical, doing your examinations, all that kind of stuff that is privately paid for. But if I write a prescription for a lab order or a cat scan or for you to go see the podiatrist or you know, the ENT doctor. That’s all covered under your traditional insurance coverage. And God forbid you need to use an emergency room or a hospital. That’s all covered. That’s your traditional insurance. It’s just my direct services are privately paid for.
0:25:58.8 Kurt Baker: So this is really just like a premium, right? You’re just paying, you know, you’re getting premium care. You’re getting, you know you’re getting. But you still didn’t lose anything else you had. It’s all still there.
0:26:03.8 Dr. Arun Rao: No, it’s all there, yeah.
0:26:07.4 Kurt Baker: So you know, you’re getting like that, literally like a concierge service. You’re getting that up front organization. Now talk a little bit about that because that’s always been a big thing. Just from what I do for a living as well, is it’s not just the knowledge that I have, it’s the knowledge of the group of people you’re connected to and the people maybe they’re connected to and getting the professionals to have a conversation because as a group we’re smarter than we are as an individual. And when you get everybody kind of communicating, it sounds to me like you’re part of that, making sure there’s a conversation. Because each doctor may not know what the other one’s doing. Sometimes I know that happens in my business and it sounds like it might be happening in yours. They don’t always know what all the parts are. They only see their little piece. But it’s much more important to integrate this whole thing so that it all works together. Correct?
0:26:51.1 Dr. Arun Rao: And that’s one of the main reasons that people might choose to kind of have me on board. I mean, for example, I have a patient who sees several different specialists, probably five or six. And so whenever I go out and see him, my homework is to have reached out to all his individual private practitioners, find out what have they done, what are they planning, are there anything that they’re looking out for in the coming future and communicate to them eventually what I found when I saw this patient, what medications he’s taking and what’s coming up. And I think that’s the way to really kind of keep his network tight. I think it’s also helpful for me in the sense that I don’t work for an organization anymore. So I don’t have kind of peers and colleagues on a day-to-day basis that I can tap and say, hey, what do you do in this kind of situation? Is there anything you recommend knowing that these people are available is very helpful as well. So it’s very important to maintain that network of colleagues that you’ve worked with, because you’re going to tap on each other’s shoulder.
0:27:52.5 Kurt Baker: No, absolutely. So how does this, I mean, when people get older, a lot of time there’s family involved in touching like all this, and it’s nice that they are know what’s happening. So how have you seen that affect kind of the family dynamic as people age? Obviously, I mean, I know several people, even like a chamber thing I went to last night, two of them were talking about how they had spent the last, you know, one was 120 days of parents ran out. I mean, it was all… They were doing a lot of the work. Let’s just say that because everything was a piece, there was really nobody to oversee everything. So now the children, a lot, most of the time, have to jump in and spent a lot of their time essentially becoming kind of this coordinator of what’s happening. So how have you seen that affect families in general? Like when you’re starting to deal with kind of the organization of it and things like that, what’s been kind of the response when you…
0:28:42.5 Dr. Arun Rao: I think it’s been a very positive response and I think it’s been one of relief because you can imagine how stressful it is to be a caregiver for an older adult and try to figure out all their doctor’s plans and appointments and medication.
0:28:56.0 Kurt Baker: Well, especially if you’re not an expert, a lot of times you’re hearing about these kinds of things for the first time and they send you a test. I’ve never heard of this test. What is this? What does this mean? I have no idea what they’re talking about.
0:29:04.2 Dr. Arun Rao: And in that 15-minute visit, the doctor or the provider might not be able to explain in detail exactly what’s going on. So I think families have looked on it pretty well because I’m able to kind of reach out to the doctors and talk peer to peer, find out the information and then I can bring it back to the family and translate it for them, saying, this is what the doctor is ordering, this is what it means, this is the risk, these are the benefits. Do you guys think you want to pursue it, etcetera? And just having somebody who’s able to talk for them and kind of tie the seams so that the picture becomes more clear.
0:29:35.2 Kurt Baker: So you can translate all this stuff to what we mortals understand. Have you seen it affecting just from a professional standpoint, I’m just thinking from the doctor’s standpoint I mean, if you’re talking to these other professionals, I would think that maybe occasionally, I don’t know if it’s true or not, they’ll say, oh, I didn’t know that that person was doing that. I mean, I didn’t. Oh, that’s great. Thank you. I mean, I’m good to know, right? Those kinds of things. Do those kinds of things ever come up where they may not even be aware that other types of services are being provided to their patient that may or may not affect them directly just so they know the overall health of what’s going on?
0:30:09.8 Dr. Arun Rao: Yeah, I mean, I think one of the reasons I did this was to do house calls and house calls are brilliant because a physician learns so much about the patient that you will not learn in the office. You get to see their kitchen, their fridge, the bathroom, medicine cabinet, the stairs, the area rugs, and all of a sudden pictures start clicking. Oh, this is why you’re falling or you don’t have this kind… This is what you’re eating and that’s why your legs are so swollen all the time and your blood pressure hasn’t been controlled at the doctor’s appointments or you’re having trouble kind of paying and keeping up certain things. And so now you’re making decisions about do I need to take care of this or do I need to buy my medicines and go for my medical care? So it kind of really puts a full picture on a patient and when you’re able. And the other thing is, I have time. I sit down with patients for an hour and a half, two hours, all the time, and we chat and we talk. And the amount that you learn there is phenomenal.
0:31:12.4 Kurt Baker: So what are some of the revelations you have without obviously picking out a patient? But I mean, what kinds of things do you hear about that maybe you wouldn’t hear about in a five or ten minute conversation in an office? What kinds of things that have helped you take care of them?
0:31:23.9 Dr. Arun Rao: I think you hear life story. You hear life story, you hear life experiences, you hear perspective and you hear priorities. Like, this is what’s important to me, this is what I don’t want, this is what I went through. And so it gives such a holistic and clear picture of the person sitting in front of you that when I’m going to say, okay, well, the Dr. X recommended Y procedure, this is why it might not make sense to you because it doesn’t jive with the way you’ve been living your life and what your expectations are. So let’s look at some alternatives. So I think it just gives you a better picture. And I think when I’m able to translate that picture to other providers who are not able to see these patients at home, they’re like, oh, okay. Well, thank you. And they’re relieved because they’re like, okay, I’m gonna keep this in mind next time I see the patient in the office. And hopefully it helps them tailor their care plans.
0:32:18.7 Kurt Baker: Absolutely. So you bring up an interesting point of, at least my limited experience. I know my wife’s had much more experience than I have with this, but when you go to specialists, I forget. The thing is, when you’re a hammer, all the world’s problems are nails, so to speak, kind of deal. And so when you go to professionals, I feel like they have like, we try A, B, C, D, and it may not necessarily be, maybe I should be down at D. A, B and C don’t work for me. Right. So that’s just what I’ve noticed. It almost feels like they have this natural progression where they just throw people in them because they don’t have a lot of time to analyze you. So it sounds to me like what you’re doing is saying, well, maybe A and B don’t work in this case based on what their preferences are. Let’s go to C or D. Or maybe this isn’t the exact specialist. Maybe you need a slightly different specialist in the same area. Things like that. Have you ever seen these kinds of. It sounds like those kinds of things happen where. Because there’s all… I mean, the interesting thing is just my personal thing is that there’s so much happening in medicine now and there’s so much innovation and there’s traditional stuff and you’ve got this on the edge stuff that’s kind of been accepted and you’ve got this crazy stuff that’s like…
0:33:25.3 Kurt Baker: We think it’s going to happen someday, but nobody really knows. So there’s a lot to keep track of, I guess, is what I’m saying. So depending on what your situation is, it’s good to know what’s been proven out. What are some things that look like they’re working pretty well for certain situations, and what are things that we really don’t know much about it, but so be careful. Right. That kind of stuff. So do any of these kind of conversations come up? Because I know when we have an issue, it’s like you become a research scientist pretty much everybody, or at least somebody in the family usually does. They’re like, I know my father started having diagnosis. He knew everything. It was crazy. So what has been your experience kind of consolidating that information that you see in the profession with things that maybe patients come back and say, oh, this is what I think. This is what I’m reading.
0:34:05.9 Dr. Arun Rao: Yeah. No, I think it comes down to the whole factor of time. I think medical care is complex, to say the least. And I think that’s one of the things that I enjoy doing is trying to make sense of this complexity. And a lot of times the way medical problems are approached could be algorithmic, that you have a problem in front of you are X, Y and Z present? If X is present, you go down this path. If Y is present, you go down this path, etcetera. And that might be what a practitioner in a busy setting is able to go through, because they might not have the time to sit down and tease out all the intricacies of each path. Whereas my end, I can kind of sit down and look at the patient and say, okay, these are the paths. This is what’s been tried. This is what’s been proven to be helpful. This is what’s not been proven to helpful. Here’s what the literature shows, here’s what the literature doesn’t show and what makes the most sense for you. So again, it’s really kind of making the most sense for the patient in front of you and tailoring it to what they need and taking this whole world of medical evidence and literature and kind of figuring out what is it about this that kind of applies to this patient in front of me.
0:35:22.4 Dr. Arun Rao: One of the first things that you have to remember as a geriatrician is that most medical studies exclude patients over the age of 75 to 80. Many times.
0:35:31.8 Kurt Baker: That’s tough.
0:35:32.9 Dr. Arun Rao: So just a study that showed that this blood pressure pill worked to control blood pressure and prevent heart attacks apply to your population? It very well might because those populations have been pretty well studied. But there are certain medical conditions where these populations aren’t studied. And so you have to extrapolate data from medical literature and kind of guess almost, is this something that’s going to be applicable to the patient in front of me? Or if not, what are the alternatives that we need to explore?
0:36:00.8 Kurt Baker: Is that number been around a while? Because that sounds like, to me, that sounds like a very young number since we have many, many people over 100 now. I mean, you’re missing pretty large segment of the population, I think. I don’t know what the number is, but it’s got to be pretty big. 75 and above. Right. Any particular reasons other than maybe they’ve always done it that way, why they don’t actually look at people over 75 a little bit more.
0:36:19.6 Dr. Arun Rao: So it’s changing, I think, in large part, to many organizations and societies advocating for older adults. Literature and medical research is starting to include older adults more in their studies. I think traditionally they had been excluded because an older adult quite often might come with multiple chronic medical conditions or functional problems or cognitive impairments if they were present. And those might confound or add a layer of complexity to the study.
0:36:53.2 Kurt Baker: Sure. I can see that.
0:36:54.2 Dr. Arun Rao: And so it would be very hard to kind of figure out what exactly was contributing to what. Whereas now I think there are increasing studies that include older adults. And I think a classic field is oncology. I think there’s a whole field of geriatric oncology now where you have oncologists who are trained in geriatrics. There aren’t many of them, as you can imagine, but they know how to put the Venn diagram or the worlds of geriatrics and oncology together, such that if you have a certain type of cancer that requires a certain type of treatment, what are the geriatrics issues that you need to consider to make this treatment as optimal and good for the patient? So that world is changing. It’s slow, but hopefully it’ll happen in the next several years.
0:37:42.4 Kurt Baker: Yeah. A question for me is that, I mean, I guess I found out because I associate with all these different professionals, but what are some of the triggers or some of the things, the aha moments. And maybe a patient or a family’s. Well, here’s the first question. Is it usually the patient or the family that says, maybe this is a good idea? And on top of that, what are usually some of the types of conditions where, like, maybe we need to rethink how we’re doing our medical care? I’ve heard about this concierge option, and then they start looking into it. Right. And of course, now they have to find you. Of course, you know, you’re one of, like, what, two. So I hope your. Hope your Google SEO is pretty good since you’re like, there’s not a whole lot of you. Right. Anyway, I’m just kind of curious.
0:38:26.4 Kurt Baker: What kind of triggers that. Or who usually connects you guys? Because somebody has to make that connection. Is it the individual? Maybe through another professional, through a family member? What kind of experience have you seen as far as how people tend to find you or somebody in your position?
0:38:41.3 Dr. Arun Rao: It’s usually a lot of patients that have been referred to me have come through community organizations and also care managers. Care managers are people who are social workers or nurses who kind of help organize the care for an older adult living in the community, because the family might not be in the area or the family might not have the ability right now to kind of help organize that. So they do things like the bill payments and the transportation and overseeing the house and making sure prescriptions are filled and things like that. And they might recognize that this person has very fragmented or limited medical care and is not able to get to them. And they say, hey, we know a doc who’d be able to come to the house and help you out with this. I think the other is kind of a lot of it is word of mouth. And I don’t think older adults themselves might be reaching me out directly, but a lot of their family might be. And it’s family that is witnessing an older adult go through changes in health function, cognition, and is starting to get overwhelmed. You know, this is an older adult who’s been in and out of the hospital several times or has been in and out of a nursing home.
0:39:50.2 Dr. Arun Rao: Or is starting to fall a lot in their house or has become vulnerable to financial issues and is starting to kind of change their pattern of thinking something’s going on here. And so that’s a lot of ways people have kind of come to me. The other way, honestly, is elder law attorneys.
0:40:07.4 Kurt Baker: Right. Sure.
0:40:07.7 Dr. Arun Rao: They do a lot of planning for older adults, especially between the estates and all that kind of stuff. And they also recognize that these older adults might be going through things that are not being addressed. And so they might reach out to me and say, hey, are you able to help out in this situation? One area definitely where that’s helped is, unfortunately, there are adults who are starting to have difficulty making decisions for themselves, and they might need to go through what’s called a guardianship procedure. And you need an assessment of capacity before you go through that guardianship procedure. And so a lot of elder law attorneys have reached out to me to help out with that capacity evaluation.
0:40:46.0 Kurt Baker: Oh, so you can do that as well, then?
0:40:47.6 Dr. Arun Rao: Yeah, I can do that. Yeah. I’ve also helped out with older adults who are transitioning from the community and are about to enter an assisted living facility or a skilled nursing home. In that situation, they need a history and physical. They need certain labs, they need certain tests, and they might need certain prescriptions to kind of be active for that transition period. And they might not have been able to get to their physician or their physician might not be able to get to them. Or they might. I’ve had several people who have not seen, seen a physician in five or seven years.
0:41:17.0 Kurt Baker: Oh my goodness.
0:41:17.8 Dr. Arun Rao: Because of access issues. And so there’s somebody who needs a physician to come out and do the assessment at home and do the paperwork and get all the orders and stuff like that so that they can transition.
0:41:28.1 Kurt Baker: No, that’s fantastic. So where do you kind of see this industry headed? So you’ve been involved in a fairly short period of time, but you’ve been doing the work for a long time. So when you blend that long term experience with this relatively new concept, how do you see this kind of progressing? Where would you see this industry that you’re “creating”, in the next five to ten years progressing with everything that’s happening right now, just in general.
0:41:57.0 Dr. Arun Rao: Wow. I didn’t think of myself as creating an industry. It’s pretty neat to think of it that way.
0:42:01.8 Kurt Baker: There you are, you’re doing it. You’re definitely doing it.
0:42:05.9 Dr. Arun Rao: What I hope, I really do hope is that we find some way to allow physicians to spend more time with their patients. Physicians want to do that for the most part. And without being allowed to do that, I think there’s so much fragmentation, so much mixed messaging, so much miscommunication, so much that goes missed. And that traditional physician patient relationship has basically been eroded and chipped away. So if we can find some way to have physicians spend more time with patients, I think that’s going to be a critical thing. And I think the other thing is medical care at home. I mean, I think it’s been overlooked. We haven’t done it. It’s done in small pockets here and there throughout the country. But I think medical care at home is a very rewarding way to practice as a physician. I walk around or drive around with my backpack, with my stethoscope and blood pressure cuff and, and thermometer and stuff like that.
0:43:08.0 Kurt Baker: You don’t have that little medical satchel that I’m thinking of from the 1800s? Probably didn’t have enough stuff in it. Right.
0:43:14.8 Dr. Arun Rao: I’m the backpack generation. Okay.
0:43:16.6 Kurt Baker: No, it’s cool. I love it. I love it, I love it, I love it. I love it. Because they can do other tests at home too. Because sometimes people think there’s… I mean, it’s pretty advanced. A lot of these things that we think of, they have to go. You can actually have it brought to them a lot of times.
0:43:30.0 Dr. Arun Rao: And that’s actually been eye opening for me as well because it’s a learning thing. So I can get… I know dentists who come to the home and can do full dental care, even possibly extractions at home. Pediatrists have been going into the house for a long time. There’s optometrists who come to the house so you can get your basic eye care and glasses. There are lab services so I can get blood draws and everything like that done at home. And these would be covered by their traditional insurances. I’ve had EKGs done at home. I’ve had echocardiograms and ultrasounds done at home. So there’s a wealth of things that can be done at home these days, thanks to technology. And so it’s really fun to do primary care at home because I can write for labs or an X-ray and I can get it done and the patient doesn’t have to go anywhere.
0:44:18.5 Kurt Baker: That’s awesome. This has been wonderful. Any final words before we have to leave today? You’ve been fantastic. This has really been enlightening. I appreciate it.
0:44:24.3 Dr. Arun Rao: No, I mean, I think, I hope people kind of start appreciating what geriatricians do and what’s available out there for them and that house calls aren’t gone. House calls are still in the area. And obviously, as an entrepreneur and a business owner now, if you’re interested, then reach out to me. I’m happy to kind of talk through and see if this is something that would be right for you.
0:44:46.7 Kurt Baker: Well, thank you very much, Doctor. We really appreciate it. You’ve been listening to master your finances. Have a wonderful day.
