Expanding Access to Dermatology Care with NexHealth: Insights from Gil Messer

Alec Goldman:
Welcome to How I Grew My Practice, a podcast presented by NexHealth. I'm your host, Alex Goldman. In this episode, we have Gil Messer, COO of the dermatology specialist here in New York to discuss expanding access to anyone with skin. Gil, welcome to the show. How are you doing today?
Gil:
Good, thank you for having me. I'm excited to discuss the expansion of access and how we've done that with NexHealth over the years.
Alec Goldman:
Well, we're really excited to have you here. For the folks in the audience who do not know you, Gil, if you don't mind just share a little bit about yourself and how you ended up in the seat that you're in with the dermatology specialists.
Gil:
Sure, happy to. So I've been in healthcare most of my career post-college and I was fortunate enough to meet Dr. Rich Park who founded CityMD Urgent Care. CityMD had this mission to really provide access to the single mom with two kids and working two jobs and had nowhere else but the emergency room, as well as the mother on the Upper East Side who was a stay-at-home that had help, et cetera. So, everybody that needed help and... And we grew that, I joined them around 30 something sites to 123 sites. And I never thought I'd probably work in another private practice again because there weren't many that were focused on serving all patients and expanding access. And then it's fortunate enough to meet Dr. Bobby Buka, who had at the time 13 dermatology clinics in New York. I joined on as the CEO and we leveraged a lot of experience from CityMD to rapidly expand. and become the largest dermatological provider in the New York City area with now 40 plus sites and seeing north of 2,000 patients a day.
Alec Goldman:
That's quite impressive. I know the last time we spoke, just hearing those numbers and from your origins sort of when you guys started and all the way to where you guys are now. So congrats, it's really exciting stuff.
Gil:
Thank you.
Alec Goldman:
So, when we talk about expanding access to anyone with skin, right? Like talking about the dermatology specialist mission, but what does that mean to you and your organization and why is it such an essential focus to what you guys are doing?
Gil:
Yeah, I think there's a unique stat out there that talks about if you need to see a dermatologist for a medical derm, the average wait time is about 22 days. If you need to see them for Botox, it's four days. That's a huge issue. Rashes, and skin issues, don't have a 22-day wait period. And so what we focus on is the ability to meet that demand. for every New Yorker, for every ethnicity, for every gender. So, you know, we are heavily populated in areas that are traditionally underserved from the Bronx through parts of Brooklyn, and Queens, as well as areas that are potentially quite over-served and like Upper East Side, Upper West Side, et cetera. And so we view it as that if you have a skin issue, you should be able to receive high-quality care. that matches your schedule in a timely manner, and it shouldn't be based on your socioeconomic status.
A lot of people in dermatology focus on being on the third or fourth floor, and only accept cash pay or commercial insurance. And that leaves a large group of New Yorkers without access to derm care. And we are really trying to break that mold. We also believe in extended hours are people work late. People can't get out of work because they're hourly employees at times. So we have extended hours. We are usually open from eight to six, and nine to seven in most locations, as well as being open seven days a week. And we'll go even further than that, we actually open 365 days. So during major federal holidays, while we have reduced sites, we have at least one or more sites open in every borough for people, because there are emergent skin issues and we are here to serve the community. And so we will be open 365, we're open 365 days. with extended hours to meet the patient's need for access to high-quality care.
Alec Goldman:
It almost sounds intuitive, like why would it be such a delay to get seen for something as important as your skin? And it's really exciting to hear that as a New Yorker, this opportunity for me to be able to be seen much faster, I guess specifically as a redhead, right, has the opportunity to be seen faster. But can you discuss why have there historically been before your organization has kind of changed this? Why have there been such high barriers? for dermatology to be providing better care. Could you talk perhaps a little bit about the private equity angle and how it's enabled your scale to not just grow the organization, but grow it in a way that's providing much, much better care.
Gil:
Yeah, absolutely. So I think broadly speaking, DERM is restricted by the number of dermatologists you have. And so nationwide produces right around 500 new dermatologists a year. The residency size program has not expanded that much over the years. At the same time, our population has expanded, and gotten older. with longer experiences of being in the sun, which means more skin-related issues. So the demand is increasing, but the supply of traditional dermatologists has stayed flat over the period of time. And so one to do that is you have to develop strong mid-level support to be able to manage the demand. And so we've been very fortunate to have a very comprehensive fellowship program where we bring in experience. PAs and MPs go through an intensive four-month, 50-hour week training program for four months straight.
They rotate with our doctors and learn everything from surgical to procedures through general derm and acne. And we're fortunate enough that there's, we get about 200 applicants for each fellowship spot that we open. And so we were able to build out a very strong core training program. that allows us to supplement our dermatologists and enable us to have those extended hours and those weekends. Additionally, I think you look at the reimbursement structure, which has made it untenable for some dermatologists to treat every patient even if they want to. Some of the managed Medicaid and Medicare Advantage plans of reimbursement would be considered not sufficient enough to build an office in a certain area and recoup that cost in a timely manner. We're fortunate enough to have great financial backers being that is a private equity firm that has provided us access to capital where we have been able to go and traditionally under serve areas knowing that it will be predominantly a managed Medicaid or reimbursement rate that while their demand is there the revenue is not the same and so it's going to take a longer period of time.
To recoup that investment and some multimillion-dollar investment opening each site and in some of these areas. And without that backing, we wouldn't be able to do it. And a lot of dermatologists are single or double practices and they don't have that access to capital and can't make that multi-year investment. And so, you know, I do think there's a lot of positives of having a great financial backer that leaves in your mission to serve all New Yorkers with skin and is able to provide those financial resources. And it's probably a little taboo, private equity, and health care, but I think it's gotten a lot of a bad rap. You'll see that CityMD was able to serve so many New Yorkers and New people in New Jersey, etc. Because of the backing that we had in the place as well through private equity. It's almost like it's your partner. Who's it's if you choose the right partner, it's a great experience.
If you choose the wrong partner, it can be bad for the providers and the patients. That's also no different than nonprofits. I know several providers and staff members that have worked in nonprofits that had terrible experiences and then they worked at other nonprofit hospitals that had great experiences. So I don't think it's really private equity dependent. It's really about who's the right partner, be it for profit or not for profit.
Alec Goldman:
Yeah. And, you know, I know that this is something we spoke about, but it is at some level, it's a little strange that the private equity-like taboo exists when really to your point, it's just about finding somebody who believes in your mission, what you're doing. There are lots of good people in any industry. Uh, and one, you know, to promote and support all of the New Yorkers getting immediate access to skincare. Um, I guess moving on to kind of our next question, it's just, how are you You're providing tons of not just locations, but increased hours, extended days, holidays. But what are some strategies and technologies that you think have been most effective in reaching a broader audience and expanding access to your services?
Gil:
Yeah. So I think it's a mix of technology and location. So we realize that we serve a broad segment of the population. That broad segment ranges from their technology access and comfort level to being very high to being very limited. And so we put us, all of our locations, I think it starts with locations, which is not technology driven. Identifying those locations is actually very technology-driven. We have a, not fully AI, but a predictive analysis of what location would be perfect from all of our experience at other locations. So first we identify the area using technology that we think is going to be great. We then put that in a retail-based location for access with great signage near public access transportation. So for the patient that is just walking by, that has an issue that needs to be addressed, they see us, they're able to walk right in. Also, that's people are a lot of times that is everybody, regardless of age range, but it's also in certain neighborhoods, a lot of the older population, they pop in, what's this new in the area? Oh, you take my insurance. Oh, you have these hours. Oh, I can join. So it starts with technology identifying the spot. And then for the rest of the population, technology really drives our booking. So we partner with NexHealth to drive our online scheduling. It allows our patients to be able to identify where they are and see all of our providers’ availability. and see who they're gonna see, and choose the time that works for them best. Additionally, they get active communication. We know with life, things change, especially in New York, life can change on a dime, where everyone's busy. So if the appointment doesn't work for you, you're able to text back, cancel your appointment, text back, rebook your appointment, et cetera. So we're really focused on being able to drive an online experience, and we're very close to rolling out a secondary partnership with TrueLark, which leverages NexHealth as well to enable further text-based appointment and communication resolutions. We also have a robust call center that has extended hours and works 365 to be able to take online bookings and answer your questions. So we try to really couple it from location and hours and the walk-in to the more traditional phone base to the more modern. web-based into the most current, which will be text-based. And so we hit every mode of technology to drive bookings, but also to drive the access.
Alec Goldman:
How are you guys leveraging kind of the standardization of technology to measure each of the locations and understanding what's working from location to location across the organization?
Gil:
Yeah, so I think one of our secret successes is that we've actually standardized the schedules across all providers and all locations. So having that standardization allows you to maximize the schedule and see the most, or support and access the most patients in a day. And so what we're able to measure is really, we'll see that certain locations are a younger population and they are gonna book within. 36 hours tops. And so those are the sites that you're gonna see a rapid climb in a very short period. I mean, there's one of our sites that is very young and just moved to New York neighborhood. And I kid you not, that site will get about 80% of the bookings from 6 p.m. until 4 a.m. the day before. Then we see more traditional, more neighborhoods where you have more developed families with older kids, et cetera. And that booking is gonna really be one to two weeks out. So we obviously display one to two weeks out, et cetera. Then we also realize where we know there's a high walk-in rate and a high no-show rate.
We are able to double, or triple book in those spaces because we know there's gonna be a high cancellation. So that single, that three slots are actually gonna become one using predictive analysis. And then we also sometimes we know the huge walk-in volume, that schedule starts, we might cap that schedule. at 35 patients knowing that 10 to 15 are going to walk in on the same day. So our schedules will tell us a lot about the patients that we're going to see, but also tell us how we need to design our operations. And then we're, we're able to leverage our scheduling software to be able to match that. And so it has seamless operations.
Alec Goldman:
really cool how you guys are learning so much about, I guess, the demographic of each location and how that affects how people book and when people book.
Gil:
It's unique. It's, you know, I think I've been in healthcare now for 12, 15 years, I think close to 15 years, and everyone says, oh, my site is unique. It's really funny when you see the data that while sites are unique-ish, you have big groups that are very comparative. So I can now launch a new site and with 99% accuracy tell you how busy it is. what's the ramp time, what's the patient insurance mix gonna be, et cetera. So they're not as unique as we used to always think. They're very much groupings into certain types of groups that we can then tell you what's gonna happen and we're pretty much right. So it's kind of really cool, but it was one of those things that you couldn't have done five years ago because the technology didn't really exist.
Alec Goldman:
It's really specifically, I guess, can you talk a little bit more about the types of groupings that you see?
Gil:
Yeah, so I mean, we factor in about, I think it's 14 different social economic indicators that will tell us the patient population and volume that we're going to see. And then in a certain neighborhood, and then you lay in the exact spot, then we know the foot traffic, etc. So we're able to use foot traffic data as well to drive it to then be able to protect what's the patient's volume going to be, how many walk-ins are going to be, what's the insurance mix, et cetera. And then we're also able to say, hey, even though this site might be in Queens, all the socioeconomic data, location, foot traffic, looks like a site that might be in another area of Brooklyn. So this is likely a pair. And then we're over to lay the ramp by that old site to this site. And you'll see the line basically hover the exact same way. And so that's, I think we use the 16 main indicators and you overlay it, you can then really pick out what site looks like what site and then know what it's gonna do in the future.
Alec Goldman:
Just for folks on the show, I'm not sure if you meant exactly the number, but how many locations is a derm specialist at now?
Gil:
Right now we're at 40 open and we'll finish this year with anywhere from 42 to 44. And the next year we'll be pushing close to 60.
Alec Goldman:
Big jump.
Gil:
Yeah, it's been fun.
Alec Goldman:
Sounds like it has a lot of scale. What are innovations that, you know, derm specialists, your organization is looking into that you think is really gonna help you guys scale to attain that speed?
Gil:
I think a lot of it is behind the scenes around our operational reporting. We're working on it, we know we've gotten down a predictive analysis now of knowing what a ramp is going to be the volume. We're able to now do staffing models based on that volume to make sure we have the right staffing at each site. So the right staffing at the right time. And make sure that it ensures that the patients have a great experience, that the providers are supported, and that we are not scrambling at the last minute to fill space, etc. The next phase, I think of that experience on it, it's where we're able to take common denials and be able to say, okay, we know this denial came in. It was tied to this person for this reason. So we're working on operational dashboards to really go back to the individual level because we can only do so much on broad training. I think we have a very strong foundation when it comes to broad training. We have a whole skin academy, which ranges to at minimum two weeks of training before you hit the sites. But what we see is that gets you to 85-90% where they need to be. And then each new person makes the same mistake over and over again. And so it's being able to capture that. drop, present that to the manager in a timely manner, and enable that manager to understand what it's showing and then retrain that person to empower them so they don't make those mistakes going forward.
Nine out of 10 times that person doesn't realize they're making that mistake. And it's just retraining that you fix it. So it's really about bringing those small things behind the scenes forward. It's going to also be with some of our payments. How are we able to present predictive to the patient ahead of the visit? What's the cost going to be? Providing them the option to prepay it. Maybe that prepayment's a buy now, pay later. Maybe it's pre-setting up a payment plan with us. Maybe it's all up at the front. Maybe it's waiting till everything runs through insurance and then seeing if that prediction was accurate. It enables a better patient experience for convenience on pain. We've already launched text-to-pay. post visit, but there are other ways that we can online chat at our portal to enable payments for them as well, any questions, refills, et cetera. So it's going to be more around the back end and not necessarily as much patient-facing that's going to drive a better experience for our providers, our employees, and most importantly, our patients.
Alec Goldman:
Sounds though that the amount of measurement you're doing is certainly a way to not lead into like an overextension or dilution of the core values and the quality of service that people would expect.
Gil:
100%. I think that's the, While it seems like we've ramped very quickly, you can make an argument that we haven't ramped as quickly as other businesses that are seeking this demand because of that quality. You know, we maintain a strict internal ratio of what the clinical quality must be at each site, how many MDDO days must be at each site, and what's the oversight of anyone who's not an MD or DO. We run a significant number of reviews for each one of our supervised mid-levels that their supervising provider has to review a high number of. Well, they have to review every one of the charts before they're signed off, but then they go into a deep dive, a clinical review on each of the charts per week.
They do quarterly reviews of overall performance, annual reviews, and the same with our site staff. So I think we've actually held back growth in some points because we are more conservative and want to ensure that if that we don't dilute the quality by opening one additional site. So we would rather book, get a lease, build out a site, and then hold. I have several sites that I'm not opening until next year because I don't think the opening is right this year. That's why I said earlier, we're over at 42 to 44 because we're gonna really make the determination. Do we open the additional ones based on the decision if it would dilute inequality? And if it does, the answer is simple. We don't open. We wait until the staff is prepared that we have the right quality and the right mix of providers to ensure that we maintain that high-quality experience in clinical care that we try to maintain at every single site.
Alec Goldman:
is going back to what we were discussing. There are tons of private equity shops who are pushing for growth and return on dollars. So it's really so important to find the right partners who understand the patience where you're not sacrificing brand quality and telling them Here's our roadmap to ensure that our brand remains our brand year over year.
Gil:
Yeah. And again, I don't, and maybe I'm just fortunate enough and I worked with several private equity groups in the past. I don't think, I don't know any of them who are willing to sacrifice clinical quality for growth because they know they made a major investment and that major investment they know is at risk if they start dropping clinical quality. So they will push for operational optimization. Maybe there is waste and labor. that could be avoided or unnecessary waste of supplies or things like that can be improved or maximizing existing staff's availability. But I don't view them as anyone that would find sacrificing quality for growth as an acceptable outcome, be that in nonprofit or for profit side, because one, we're in healthcare for a reason. No one goes into healthcare because they're looking to make money. The first reason they go in is to take care of patients. And second of all if you are a for-profit backed company, they made a major investment in you. The only way to recognize and realize that return that they're seeking is to maintain that quality, even if it takes a year longer than they anticipated.
Alec Goldman:
That totally makes sense. If you sacrifice your brand, you know, obviously long-term you're really hurting, you're damaging what would inevitably be your revenue anyway. So just optimizing for short-term over long-term or long-term over short-term. And you really got to be playing the game, especially the one that you guys are playing, which is you want to, I'm sure at some point, hundreds of locations. So without that brand promise staying in place and that reputation scaling from location to location, like that's. That's what the organization has.
Gil:
Exactly.
Alec Goldman:
Closing thoughts, we are just over 20, almost 25 minutes. For other healthcare providers, dermatology practices looking to broaden their reach. What would be your parting device or parting advice here? Just based on your experience growing derm specialist to the, you know, almost 50 locations that you guys have now.
Gil:
Yeah, patients don't live in a nine-to-four environment. Your key operating hours are their key working hours as well. We see that even more as there's been massive inflation, et cetera. And so you have to meet your patients where their need is. There are a lot of options out there and patients will self-select. If they have to choose between changing providers or losing revenue for themselves and have to take time off work, be it unpaid or paid, a lot of times they'll switch. So meet your patient where they are with your hours, but also meet your patient where they are from when they're trying to communicate with you or book with you. Putting an online request form that lets you someone fill it out and ask for an appointment time, isn't really online scheduling. Patients see that, they're usually moving on. Similarly, if it's only a phone call available and then you call five times and can't get through, they're going to call another phone number. So really moving the environment from where, moving the environment from where, hey, the patient just has to match what we tell them to the environment, we say, we have to match what the patient is telling us. The environment has enabled us to be successful and continue to grow.
Alec Goldman:
Gil, it was a pleasure having you on the show. I know I'll be seeing you in the next month in person in Long Island City, so I'm excited about that. But thank you so much for sharing all the success that you guys are doing with, that you're doing with Derm Specialist, and just giving your thoughts to the audience who are listening on the show.
Gil:
Thank you for having me and it's always a pleasure to connect. Talk to you soon.