The Practice Profit System

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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How many times does the company that employs you have to change hands before you stop calling it security? For Liz Lyster, it was three sales and a bankruptcy. She started at Cigna in 1994, when it still ran its own hospital locations in Los Angeles, and watched the model eat itself: the office was paid to keep patients out of the hospital, and the hospital was paid to put them in. Then the company was sold. Then sold again, and again. In 2000, seven months pregnant, she showed up to a crowd at the front door and a building locked for bankruptcy. The nurses handed her a few IUDs on the way out because nobody knew what would happen to them.

Liz grew up with two academic physicians for parents, so money and business were never discussed at the dinner table, and she opened her first practice with no money skills at all. I tell every doctor I work with that there is no shame in that, because the system is built to keep you from learning it. Liz and I agree that a business class in medical school is just the class people skip. What she would teach instead is independence: the real pros and cons of being employed and what you want your career to look like twenty years out. Full disclosure, Liz is a Mavrix client. We met at a dinner table on the BHRT Training Academy cruise, and she tells me straight that what she felt back then was closer to resignation. We get into what changed, and why she now lets long-time patients graduate when they won't renew at her new prices. Then we go somewhere harder: how she has had to rebuild her leadership after losing her husband, and a lesson I've been teaching lately about how most of us hire out of our own woundedness.

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About the Guest:

Dr. Liz Lyster is a board-certified OB/GYN and hormone specialist who has spent more than 30 years getting women in midlife real answers. The daughter of two Argentine physicians who trained at the Mayo Clinic, she graduated with honors from Cornell University, earned her medical degree at UC Irvine, trained in OB/GYN in East Los Angeles, and holds a master's in community health education from UCLA.

After years as an employed physician and then running her own insurance-based practice in Southern California, she now runs a cash-based midlife hormone practice and lives in Reno, Nevada. She hosts Hotness, the podcast where hormones, confidence, and desire come back online, and has written several books, including Dr. Liz's Easy Guide to Menopause, Go for GREAT, and Sacred Libido. She celebrated her 50th birthday by climbing Kilimanjaro and dances Argentine tango.

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Social Handles:

Download Dr. Liz's Guide to Midlife for free at drlizmd.com/hotness

Follow Dr. Liz for midlife hormone real talk at @drlizlyster

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Frank Shallenberger loved emergency medicine. It was fast, it was clear, and you could save a life. Then the ER started filling up with people who'd had a rash for six months, so he crossed the street, hung up a shingle, and opened a family practice. Six months in, he went to the hospital administrator with a problem. He was giving patients the right medications for hypertension and arthritis, and nobody was actually getting better. The administrator went through his cases with him every week for a couple of months and came back with the answer that changed Frank's career: you're doing everything right. Frank responded that if this is doing it right, then something is missing.

What he found was a study group run by Linus Pauling. Before each evening meeting, the physicians would spend the morning wandering the stacks of a university library basement, pulling periodicals going back to the 1800s and bringing whatever looked interesting to the group. No internet, no Amazon, just yellow legal pads and a librarian who made copies. A few years later, as program director for a meeting of the Orthomolecular Medical Society, Frank booked a speaker named Charlie Farr, who was infusing an oxidant into patients at a time when everyone in the room believed oxidants were the problem. That talk, and Paracelsus's old line that the dose makes the poison, set the direction for the next 40 years. It also got him into trouble with the state of California, which is how he ended up in Nevada in 1991.

The part I wanted every doctor listening to hear is what his practice looks like now. Frank runs a 15,000-square-foot clinic with three nurse practitioners, a naturopath, nurses, and an IV room, and every new patient is tested before Frank walks into the room. He's 80, he still loves the work, and he told me that if he ever retires, it'll be because of the red tape. We also got into the business side: what ozone sessions go for in big and small markets, why they're sold as a series, and where to get trained. I've been to Frank's big conference and his smaller Reno trainings, and most of the functional medicine doctors I work with have been through them.

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About the Guest:

Frank Shallenberger, MD, HMD, ABAAM, has been practicing medicine since 1973 and leads The Nevada Center for Alternative & Anti-Aging Medicine in Carson City, Nevada. He trained at the University of Maryland in one of the country's first shock trauma units, spent close to a decade in emergency medicine, completed a surgical residency in California, and then opened a family practice. His search for why patients weren't improving led him into Linus Pauling's orthomolecular study group in the San Francisco Bay Area, and later to Nevada, where he has been licensed by both the allopathic and homeopathic medical boards since 1991.

Frank is one of the early pioneers of ozone therapy in the United States, a field he began researching in the 1980s. He helped form the American Academy of Ozone Therapy, which certifies physicians, dentists, and veterinarians, and he teaches its medical track. His clinic spans about 15,000 square feet and includes an IV infusion room and in-house testing for mitochondrial and endothelial function, including a computerized oxygen and carbon dioxide analysis system he developed about 25 years ago. He is the author of Bursting with Energy.

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Learn about ozone therapy certification for physicians, dentists, and veterinarians at the American Academy of Ozone Therapy: aaot.us

Request an appointment at Frank's Carson City clinic at antiagingmedicine.com

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