The Practice Profit System

Sally Primus showed up in my LinkedIn feed with a post about reimbursement rates, which caught my attention because my feed is usually orthopedic surgeons and pain management doctors. She's an ophthalmologist who went out on her own five years ago and learned most of what she knows about the system the hard way.

We follow the money on Out of the System, from the medical loss ratio rules that tie an insurer's profit to total spending to the way large parent companies can own the plan, the pharmacy benefit manager, and the practices all at once.

Then I put my business school hat on, and we play out what happens if Congress bans private equity from owning practices. Sally's view is that a ban leaves the real problem in place, because a thriving practice hangs up on the private equity guy, and the ones that sell are already struggling. She has spent the past year studying other countries' systems for her audience, and the one she keeps coming back to is Australia, where everyone has a public plan and a private market sits on top as a release valve. We finish on her own exit plan. She's 41, works four days a week, and is weighing a move to three, and between her videos, courses, and newsletter, social media now pays her mortgage. If you're in an insurance-heavy specialty and wondering what independence costs, start here.

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About the Guest:

Dr. Sally Primus, MD, is a board-certified ophthalmologist with an independent practice in southern Indiana. She spent five years as a partner in a larger group before going out on her own five years ago, and she completed an extra year of training in oculoplastics, the surgical specialty that covers eyelid reconstruction and skin cancer removal around the eye.

Under the name Slice of Life MD, she explains how the United States healthcare system works and how other countries handle the same problems. She has more than 100,000 followers across social media, writes a weekly Substack newsletter, and teaches short courses on Medicare and insurance appeals.

Substack: https://sliceoflifemd.substack.com

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About the Host:

Matthew Gillogly is the host of Out of the System and the founder and CEO of the Mavrix Profit System, where he goes by Chief Maverick. He is not a doctor. He is an operator who has owned cash-based medical practices and run retail and restaurant businesses, and he geeks out on pricing the way his clients geek out on the gut microbiome or joint pain.

He built Mavrix to help physicians move out of insurance-dependent care and into cash and direct-pay models, and he is the author of Out of the System: A Doctor's Guide to Reclaim Your Power, Purpose, and Passion. His mission is to lead 100,000 doctors out of insurance-based care worldwide.

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Here is a conversation I have with doctors all the time: I ask how they priced their hormone program, and they tell me the patient pays for the appointment and every follow-up gets its own fee. Then I ask how they built it, and the answer is that they modeled it on the insurance system because that is what they knew. That is the mistake I spend time on with my morning coffee on this episode. When you charge patients every single time they walk in, what we see across our clients is that they stay around three and a half months. They get buyer's fatigue. The program looks like insurance, so their brain expects it to be paid like insurance, and every trip to the wallet feels like the plan let them down.

Think about season tickets. Years ago, when I had season tickets to the theater, I went to most of the shows. When I bought them one at a time, I kept forgetting. A package of several modalities used together works the same way, and patients use more of what they signed up for.

Doctors assume patients want everything covered, when what patients tell you is that they are tired of being sick. And doctors set prices by polling colleagues at a conference, which assumes the colleagues know what they are doing. I ask how many of your doctor friends have been to business school or run a retail operation.

Your price is a message about your value. Charge what the work is worth, show the patient why your program is more thorough than the one down the street, and stop sharpening your pencil to come in a dollar under everyone else.

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About the Host:

Matthew Gillogly is the host of Out of the System and the founder and CEO of the Mavrix Profit System, where he goes by Chief Maverick. He is not a doctor. He is an operator who has owned cash-based medical practices and run retail and restaurant businesses, and he geeks out on pricing the way his clients geek out on the gut microbiome or joint pain.

He built Mavrix to help physicians move out of insurance-dependent care and into cash and direct-pay models, and he is the author of Out of the System: A Doctor's Guide to Reclaim Your Power, Purpose, and Passion. His mission is to lead 100,000 doctors out of insurance-based care worldwide.

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A friend of mine, Kevin Nations, once told me you can't sell heaven without hell. For most of my career, the data agreed with him. Alicia Munian doesn't buy it, and it became one of my favorite debates on Out of the System. Alicia builds marketing for mission-driven clients, and her view is that social media has turned advertising into a two-way conversation. When anyone can reply in the comments, she says a negative message lands differently, and the person behind the practice carries more weight. I push back and tell her about a headline from my men's health clinic days that ran for six months because it used a patient's own words. We land closer together than either of us expected: the copy works when it sounds like the person you're trying to reach.

Then we get into what actually keeps doctors off camera. Alicia was 20 and in the hardest season of her life when a professor handed her Thich Nhat Hanh's Peace Is Every Step, and its lesson about washing the dishes, noticing the warm water on your hands, became the way she helps clients reframe the things they've decided they hate, posting on social media included. She walks me through how she uses guided meditation to surface the blocks beneath a doctor's marketing, and I share a mastermind story about a client who kept hiring the wrong people for reasons unrelated to hiring. If you're a physician who would rather do anything than make content, start here.

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About the Guest:

Alicia Munian is a digital marketing specialist and the founder of Intuitive Marketing Mind, where she builds websites, social content, SEO, and marketing strategy for mission-driven clients, including coaches, wellness practitioners, and doctors. A first-generation Guyanese American, she studied political science, worked on political campaigns, and later managed marketing for Cross-Cultural Solutions in Costa Rica, an organization running international health and education projects.

Her approach, which she calls attraction marketing, puts a client's story and their clients' potential at the center of the message. She pairs strategy with meditation, somatic work, and hypnotherapy to help clients find what's holding them back from showing up as themselves.

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Social Handles:

Website: https://IntuitiveMarketingMind.com

Instagram: https://www.instagram.com/aliciamunian/

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Most doctors I talk to think of UnitedHealthcare as an insurance company. The insurance arm is the least profitable part of what it actually is. I recorded this one live from a conference in Chicago, the second round of Saturday Morning Coffee with Matt, the morning after a welcome reception full of chiropractors and physical therapists telling me they don't know how much longer they can hang on. So I treated UnitedHealth Group the way we treat a company in business school, as a case study in how you take control of a market.

I walk it through Betty. Her insurance card says UnitedHealthcare. Her longtime doctor now works for Optum. Her prescription runs through Optum Rx, the nurse who visits her living room comes through a program run by her insurer, and the claims run through Change Healthcare, which Optum also owns. If an independent physician owned a piece of the surgery center and the rehab facility he referred into, the self-referral rules would stop him. When one corporation owns all of it, the doctor is an employee and the structure stands. Then I follow the money from the premium cap on the insurance side to the payments that move between divisions, and into the research comparing what UnitedHealthcare pays its own practices with what it pays independents for the same work. Medicare Advantage adds another layer, because it pays more for a patient with more diagnoses on the chart. Federal inspectors have called billions of dollars in those diagnosis payments questionable. No court has found fraud, and the company says its practices are appropriate.

Then we get to you. If you own your practice, look up what your biggest payer pays the practice it owns down the street. Rank your payers and look hard at the ones that pay least and slowest. Build services your patients pay you for directly, something you want to be great at, and once you're outside the insurance model, you get to design the patient journey around the patient. I expect the fix to come one practice and one patient at a time, from doctors who stop waiting on Washington.

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About the Host:

Matthew Gillogly is the host of Out of the System and the founder and CEO of the Mavrix Profit System. He is not a doctor, and he treats that as the advantage. While physicians were learning anatomy, he was learning business anatomy, and he brought it into medicine as an operator. He ran three clinics in North Carolina under a management arrangement built by the letter of the law, where the doctor owned the practice and made every clinical call. His company handled the business side, and those clinics became the number-one provider of men's sexual health solutions in their market before he sold them.

He built Mavrix to hand that playbook to physicians who want out of insurance-dependent care, and he and his team have worked with hundreds of doctors on cash and direct-pay models. He spends most of his time making the case that the system works exactly as it was designed to, and that the people it works worst for are the ones who trained the longest.

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Four weeks before his trial, Dr. Muhamad Aly Rifai got permission from his pretrial officer to drive two hours to the federal prison in Otisville, New York, and look at it from the outside. He wanted to know he could live with the outcome if the jury convicted him. Dr. Rifai is a psychiatrist and internist who brought telepsychiatry to rural Pennsylvania in 2006. Years later, an audit of his notes became a federal case claiming he billed 20-minute visits for calls that lasted two or three minutes. He walks me through how that case came apart at trial, including the moment the government's own coding witness told the jury she did not support the prosecution, and what it was like to hear 48 "not guilty" answers when the jury was polled.

We also get into what six years under that pressure did to him. He went from 250 to 400 pounds in about two years, with food as his comfort, and eventually admitted he couldn't treat himself and started seeing a counselor, a fellow psychiatrist. From there we turn to the business side of Out of the System. An insurer's prepayment review pushed him to cash pay, and his patients stayed at $200 for 20 minutes because they couldn't find another psychiatrist they liked. He also shows me where ketamine, TMS, and the Kernel brain-scanning helmet fit into the practice he's building now. And we spend real time on something I keep seeing with my own clients: the family patterns and generational trauma that sit underneath why one doctor grows and another stays stuck. If you've ever wondered what you'd do with the full weight of the system pointed at you, start here.

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About the Guest:

Dr. Muhamad Aly Rifai, MD, DFAPA, FACP, is board-certified in internal medicine and psychiatry and is CEO of Blue Mountain Psychiatry in Pennsylvania's Lehigh Valley. He trained in a combined internal medicine and psychiatry residency at the University of Virginia, then spent three years as a researcher at the National Institute of Mental Health, where his work included early studies of ketamine for treatment-resistant depression. He has practiced in rural Pennsylvania for about 20 years and began offering telepsychiatry there in 2006.

In May 2024, a federal jury acquitted him on all charges in a Medicare fraud case built around his telehealth billing. He tells that story in his book Doctor Not Guilty and writes about addiction in Hijacked Minds. His practice now uses ketamine, transcranial magnetic stimulation, and the Kernel brain-scanning helmet to help people under pressure understand and improve how their brains are performing.

Read Dr. Rifai's story in Doctor Not Guilty and his other books at DrRifaiBooks.com.

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