Reimagining private practice

Show Notes

Dr. Nitin Gupta is the founder of Rivertowns Pediatrics, a very different type of private practice. Having practiced from Newark, NJ to Caribou, ME, he’s landed on a value-based, concierge model that works. Boiling things down, Dr. Gupta told Daniel, “You're spending more time on that computer than you are face to face with that patient.  This gives you the opportunity to be the doctor that you were meant to be, and so that's why I started this.”

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Speaker 1:
You're spending more time on that computer than you are face to face with that patient. This gives you that opportunity to be the doctor that you were meant to be, and so that's why I started this.

Speaker 2:
Welcome to Healthy Conversations. Today I'm in conversation with Dr. Nitin Gupta, the founder and CEO of Rivertowns Pediatrics, a really unique and impressive concierge pediatrics practice. Well, it's great to be on with a fellow pediatrician. Tell us a little bit about your background. What led you to pediatrics, nutrition, gastroenterology.

Speaker 1:
So I was born and raised in San Francisco Bay Area to Indian immigrants. My dad was an engineer and I was supposed to go down the path of following his footsteps, but most physicians, I actually was inspired to go into medicine because of a family onus. When I was five years old, my dad suffered a heart attack when he was only 35. He was a type two diabetic, obese, sedentary lifestyle. Also, he was a consultant, so he was constantly on the road or flying around, and so at that point, whereas most kids think their fathers are superheroes and indestructible, I realized my dad was human. That's actually how I got inspired, trying to figure out how I can help my dad and save him and treat him. Nutrition plays a giant role with cardiovascular disease and diabetes, and so that led to me even to majoring in nutrition at UC Berkeley as my undergrad.
Using my dad as my inspiration, the thought was I would go into adult cardiology, but once I was in medical school, I was actually dismayed because I felt like there was just this callousness. There was just this wall between the physicians and the patients there. Then when I went into pediatrics, that was home for me, just seeing pediatricians putting in 200% of the effort. Also, I'm a kid at heart and with my nutrition background, I thought it was only normal to go into pediatric gastroenterology, but I actually hated it. I went to my fellowship, I hated it. The majority of the kids there, they didn't need to see a specialist if their pediatrician had more than five minutes to spend with them to manage their constipation or their reflux. So I was moonlighting in the pediatric ER and I loved the variety of seeing the ear infections and the asthmatics and non-GI cases. And so I eventually made the switch to pediatric ER and did that for about five years.

Speaker 2:
I trained in medicine pediatrics, but GI, boy, especially on the pediatric side, it felt like all that encopresis, and it seemed like it was more managing the parents and some of the issues that may have led to the pediatric GI issues as well.

Speaker 1:
True, true. But if it wasn't for that experience, it wouldn't have seeded my mind with that thought that really if the pediatrician had more time, they could be managing this, that constipation wouldn't have gone so far as encopresis. Even though I hated my fellowship and I hated what I was doing, it was necessary for the journey that I took.

Speaker 2:
And it does tie into nutrition. It's really quite rare to see physicians with much background in nutrition at all, and in medical school, I think we maybe had three hours.

Speaker 1:
When it really should be part of throughout our training,

Speaker 2:
Where apparently the data is if you give a child when they're six months of age, their first solid food essentially, often it's that white rice cereal that is tasty, and kids like. If you change that to a whole grain cereal as opposed to white rice, which might be cheaper and sweeter, you end up with a different microbiome and epigenics and much lower risk of obesity and type two diabetes downstream. So nutrition, particularly in our field of pediatrics, particularly early, has a huge lifeline influence.

Speaker 1:
And that's where pediatrics, I think, is unique compared to other specialties because our focus mainly is on prevention more so than anything. And I kind of sit back and I think, well, this is our wheelhouse here. That's all we do in the fall and winter is dealing with the infection control. So one thing I wish is that there was more pediatric involvement, especially now we see with Delta really affecting the kids more throughout the southeast.

Speaker 2:
Any insights on how pediatricians can get more involved outside of their day-to-day clinical practice with their community public health and maybe their school systems?

Speaker 1:
Well, absolutely. The opportunities are there. During the past 18 months, I've remained definitely involved in with our PTA as well, but also contacting directly our school systems, our local governments. I was in talks almost weekly with our mayor. We even made recommendations for our grocery stores to have one direction aisles so that we would avoid the cross contamination. What I do also recommend to all pediatricians, if there isn't an opportunity, make one speak up. Social media is a good platform, but even just calling and emailing local officials, it is really our time to speak and protect our kids,

Speaker 2:
And that goes for any medical specialty I believe as well. Yeah. You grew up in California, but you spent time on the northeast coast from Brooklyn to Maine. How did that inform your career path and choices? Any advice for folks earlier, let's say in their clinical careers?

Speaker 1:
We don't know where we're going to end up. It's pretty rare for a physician to even go to a local medical school and then stay, do a residency in their local hometown. So I think all of us physicians really understand that we are always subject to the match. So I ended up here in the East coast because of obviously medical school and residency, and I tried to make my way back to California. The more I tried, it seemed like the more New York, kept pulling me back in. For fellowship, I thought I was definitely going to Stanford and then I opened up Match Day and oh, I'm going to Cornell. So then at that point I realized I'm a New Yorker. Fate has it in for me. I'm never leaving New York. So I stopped trying. So the different locales and the different settings, a lot of that had to do with me trying to figure out who I was and where I'd be happy.
Maybe it was, I grew up thinking about those Hollywood doctors and being there for their patients, being available, watching those old black and white movies that somebody got sick, the doctor came to the house. I was constantly looking for that job, and so that's how I ended up residency in inner city Newark. Then Fellowship to Wealthy, Upper East Side Cornell. And then after I left Cornell, my father had actually passed away, and so I actually wanted to give up medicine altogether, but it was hard for me because I dedicated so much of my life to going into medicine and I just wanted to be at the farthest place I could go. So Caribou, Maine came calling and they needed a doctor in the dead of winter from January to March, and I said, you know what? I'll take it. Every location had their own different needs. Inner city Newark, you were dealing with food insecurity and asthma. Upper East Side you're dealing with anxieties and mental health. Going up to Northern Maine, I was dealing with cold injuries or tickborne illnesses.

Speaker 2:
You're talking about sort of the inspiration of the pastors, the Dr. Wellby shows. There was the Northern Exposure Show about the [inaudible 00:07:35].

Speaker 1:
Northern Exposure, that was me. There literally was a moose walking down Main Street. It got down to negative 32 at one point, but it was the most enlightening experience because that was the most community oriented experience ever. My nurses, they knew all of my patients and they would pull me aside and say, "Well, this patient, they're really poor. They were brought here by their neighbor. They have a dirt floor, they're here for this, but let me give you the background." And the community really came together for each other. Of course, my wife was back in New York, and so eventually I had to come back, but it was hard for me to come back. So I was always looking for that caribou job.

Speaker 2:
In some, I think bigger academic and other centers, you lose patients might become a number or someone you see once in a setting and you lose that context.

Speaker 1:
You're exactly right about where we are in New York. I bounce from job to job because I felt like I was a number, the patients were just a number. Just feeling almost like a factory worker and just clocking and clocking out and not being able to be at a hundred percent for my patients, that was hard. And so it led to a lot of burnout, led to depression, and at some point in 2017 I realized it's not this job or that job, it's the system and the system is broken. And so that's why I started Rivertowns Pediatrics.

Speaker 2:
So this is a bit of a watershed moment. Did you have a sun realization or...

Speaker 1:
After my son was born, after my daughter was born, I realized I'm a parent now, and boy, it's really good that I'm a pediatrician. But it made me think, what about the others? Other people don't have the access that I have. In 2017, what did it for me was, I don't know if you remember, but they defunded the Children's Health Insurance Program. It was a terrible flu season. They have these 103, 104 fevers, but they couldn't afford to actually see us because they no longer had insurance. All of a sudden, overnight, they defunded their insurance and there was no end in sight to that defunding of the CHIP program. That was one of the breaking points when I realized, wait, we are so addicted to insurance that overnight you could lose your insurance and you now don't have a doctor. That was when that moment when I realized access was the issue.
And then also at that moment we started seeing the rise of high deductible plans. I discovered that my office bill, me doing the rapid straps and the rapid flu tests and billing a 99214 giving some Tylenol that led to a $500 bill. Now you're paying hundreds of dollars until you met your deductible. So it didn't even matter that they had insurance. They still had no access to me. I realized this is not for me, I can't do it anymore. I was always one of the top billers in any institution I ever worked for. But when I realized that my patients couldn't afford to see me because I was so dead set on billing as high as I could, that's when I quit. I quit for the last time because now I've kind of jumped in headfirst on this one. This is my practice. Can't exactly quit my own practice.

Speaker 2:
So help us understand that. I mean, give us a quick synopsis of how is that practice different than a normal pediatrician practice? How does the practice work at its basic level?

Speaker 1:
I'm going to provide a hundred percent access to me. So you have me 24/7, you got my personal cell phone. You can call, text anytime, video me. My patients even know where I live. So it's like, "Hey, so-and-so has a fever." I'm like, "Hey, you know what? I'm barbecuing right now. Why don't you come over? I'll see your kid." I wasn't providing the access that my patients needed, so I decided I'm not going to take insurance. What that means is that my patients, they pay a monthly fee. Now what I charge is a sustainable monthly fee. It's sustainable on both sides. If it's too low, I won't be able to keep the lights on. If it's too high, it's punishing my patients. Taking in effect that a lot of my patients, their average family deductible is $3,000 a year. I charge them a monthly fee that's far below that $3,000 deductible.
So on average, when I first started out, I was charging a hundred dollars a month per patient. For many people who said, "Oh my gosh, you don't take insurance, you must be must expensive." They would just kind of hang up. But wait, that a hundred dollars a month, it's actually not as expensive as it sounds because if you think about it, you have a $50 copay, well, that's two office visits, that's only five minutes with that doctor, and there's no follow-up after that. For me, I could see you 30 times a month. Now if I see your kid 30 times a month, I'm doing something wrong.
So that's turned this into a value-based model as well. So it's in my best interest to make sure I keep your kid healthy. So that's where the prevention comes in, that's forecasting, making sure that my patients know that they got to get their flu shots by this time. It's on me to make sure I'm not seeing them 30 times a month. Another difference is if I see my patient for say, a strep throat, there's that follow up the next day or the day after, or my patients can text me anytime. And it's not a five-minute visit. It's often a 15, 30, maybe an hour.

Speaker 2:
And when there is a acute issue, just to be clear, the patients or the families will still have insurance to cover that strep test or the lab test or the x-ray if that comes along.

Speaker 1:
Exactly. They still have insurance. If I were to take insurance, I would have to hire a handful of front desk people to verify the insurances, to do all the scheduling. Then I'd have to hire an army of MAs to line them up in the rooms with the point of care testing and all the vitals. And then after that and then go from room to room to room, and I have to hire an army of billers just to make sure that we get paid. All that adds up. So all those overhead costs that's created a volume-based medical system. And that's unfortunate. What we have nationwide is a volume-based, and because that overhead, I have to see that many more patients. So in our area here in New York, it's most of this us pediatricians seeing at least 30 patients a day. Now, can you honestly provide adequate care by seeing 40 patients a day?
No, it's tough. So what happens after hours, after 5:00 PM they go to an urgent care. We see an urgent care on every street corner here. That's showing we have these rises in urgent cares is because people don't have access to primary care docs. So by removing that overhead cost, I'm able to have a sustainable rate of a hundred dollars a month. Of course, with the pandemic, the rates have gone up to an average of $125 per patient. The infants are charged a little bit more, but that's also to cover the cost of the vaccines. So I'm eating the cost on those vaccines.

Speaker 2:
So back to your sort of model, I mean, you've got now the opportunity to spend quality time with your patients, their families, and you take calls 24/7 and do house calls, et cetera. So what are the challenges? How have learn to balance the ability to have any downtime because you're on-call 24/7?

Speaker 1:
That's something that's brought up a lot. Now, I average about four patients a day. So what I said is I also provide a lot of that anticipatory guidance. So when I see that patient for that URI, I'm telling the parents also, look, we're going to expect that fever's going to get worse tonight. This is what we're going to do. If anything happens, let me know. In my three years, I've been called 14 times in the middle of the night.

Speaker 2:
That's incredible. You measure 14 times in a week.

Speaker 1:
No, but sometimes as soon as it's 7:01, they know I'm awake because my kids are awake. So they'll text me or call me, and that's perfectly fine. Those 14 times, they were whole necessary times to call me. Well, except for one, they were on vacation, different timezone. But the other 13 times, you know, had a lot of croup. I found that I have to space out how often I can take new patients. Newborns definitely take a lot of time, but scalability is hard. It's hard for me to find another pediatrician. I found a great one, but he won't leave Staten Island. He bought a house in Staten Island. So we opened up a second office in Staten Island for him.

Speaker 2:
And you're still able to take folks that lower socioeconomic ranges. What might you tell a pediatrician or any clinician thinking about concierges, not just lifestyle, but practice and how if you were to set it up again, what you might do differently?

Speaker 1:
What I'd tell another doctor, another pediatrician, is that really this gives you the opportunity to work for your patient to work a hundred percent at your skills. Because unfortunately, working in the systems, you don't get that opportunity to work to the best of your abilities because you're clicking boxes, you're checking off that no, that two-year-old does not smoke and you're not, you're spending more time on that computer than you are face-to-face with that patient. This gives you that opportunity to be the doctor that you were meant to be. And so that's why I started this, something that's sustainable.

Speaker 2:
And have you found a bridge of a feather?

Speaker 1:
So there are other physicians that I've helped kind of start this model throughout the country and they're thriving. And I'll tell you one thing is that it was difficult pre-COVID. COVID actually changed the game. A lot of parents realized that we're not going into a doctor's office. We need a house call. We need somebody to be available when we need them. I've just recently teamed up with some other concierge docs locally in Westchester. We do have a family medicine physician that's part of Rivertowns Pediatrics now. Because what I found was that within a year of opening, the parents who are in the practice loved what I was offering. They said, "Hey, I wish there was something like this for us." So our network is growing and I like to say the personal fulfillment for both the patients and the doctors are also growing.

Speaker 2:
So you have to be at a bit of an entrepreneur here and think about doing things differently, any sort of tools you've used, entrepreneurial mindset, whether it's technologies for virtual visits that have integrated into your practice and can make it better for you and for your patients?

Speaker 1:
One thing that I've done is all my families now, when the child's old enough, we'll get those little Bluetooth otoscopes. So that's something that they can actually send me a video of their kids' ears if they're waking up with in ear pain. But really, I actually keep it as simple as possible. And so that's where the difference is. I know I do have that entrepreneurial spirit, but I'm keeping it simple.

Speaker 2:
So on Healthy Conversations, we always want to kind of close, given that the listening audience is almost entirely made up of health care professionals. Anything you'd want to share with your health care peers?

Speaker 1:
What I want all the physicians or health care providers to know is to always remember to put the patient first. And we all know that. And it is difficult at times to put them first, and I've been there. I know, but that's who we are. And in order to make sure that they're first, it is up to us, the physicians, to disrupt the status quo. It's hard, but I did it and I'm going to continue to do it, and I'm going to help others disrupt the status quo because we know that it's broken. We have to put the patient first.

Speaker 2:
And you're a great example of someone who's felt the pain and made the change and help catalyze great new care for patients and families who can be part of Rivertowns Pediatrics, but also potentially can catalyze others. And Godspeed to you and your Rivertowns Pediatrics team.

Speaker 1:
Thank you.