ROUNDS

Issue 04 — Seeptember 2026

The Door Is Open

A monthly check-in from Dr. Brian — practice news, something to cook, and what's on my mind.

From the Practice

Hospital-to-Home

Last month I told you Hospital-to-Home wasn't ready, and that I wasn't going to give you another date. Here's the update I was saving: it's open.

Someone gets discharged from the hospital — statistically the most fragile stretch in modern medicine, and the one where the system is least likely to be watching. Within 24 hours they get a video visit with me. For the next 30 days their medications actually get reconciled, their follow-ups actually get made, and they have my number. That's $250 for the 30 days, and it rolls into a standard membership afterward if they want it. It doesn't work with Medicare or Medicaid — a real limitation I'd rather say out loud than bury.

I built it because I spend my hospital weeks watching people leave a building in a fragile state holding a stack of paper and a phone number nobody answers. If someone in your life is heading home from a hospital stay, reply to this email.

And while I have you — what this actually is

Some of you have gotten four issues of this without me ever plainly saying what you'd be signing up for. That's my fault, so: briefly.

B2 Direct Care is a membership practice. A flat monthly fee gets you me — my cell number, visits that last as long as they need to, telemedicine anywhere in Colorado, house calls, and labs and medications at what they actually cost instead of what a billing department decides. No insurance in the room. No copay. No eight-minute slot.

Adult membership is $140 a month, couples are $220 a month, a household with two adults and two kids is $300 a month, and there's a $75 telemedicine-only rate for members outside the Denver metro area. (plus a one-time $55 enrollment fee). The membership is HSA-eligible. It is not insurance and it doesn't replace it — most members keep a high-deductible plan for the things that put you in a hospital, and use me for everything else.

I'm capping this practice at 100 to 150 members on purpose. A panel of two thousand is how the fifteen-minute visit happened in the first place.

If you've been curious and never asked BOOK A 15-MINUTE CALL No pitch. I'll tell you if it isn't a fit.

Field Notes

Everything except listening

This month's How Did We Get Here post was the hardest one to write, because it's about my own working life.

Between 1970 and 2000, American medicine got extraordinarily good. CT scanners. Transplants. Chemotherapy. Statins. A baby born in 1995 could expect roughly a decade more life than one born in 1955. Those are real gains and I won't discount them for a sentence.

But look at what got built underneath them. Managed care. Prior authorization. Formularies. The thirty-minute visit that became fifteen and is now eight to twelve minutes of actual face time. An electronic record that costs about two hours of typing for every hour spent with a person — one study clocked physicians at 27% of the day on patient care and 49% on documentation.

So we ended up with the most capable medical system in human history, staffed by people who are structurally not allowed to pay attention. That isn't a moral failure on anyone's part. It's an architecture.

Direct care is my deliberate step out of that architecture. Not innovation. Recovery.

Read the blog post "Gains and Costs"

Currently Reading

I See You've Called in Dead by John Kenney

Ok, last month I mentioned that I had started this book, well, I’m still reading it. Warning: last month when I said it was “laugh out loud” that was true. But my literary instincts didn't see the detour the book was about to take; I’m still enjoying it, and almost done. Much like Theo of Golden, I’m quite curious to see how this all wraps up at the end. FYI, I’m doing my best to avoid a spoiler alert, but there are some fun parallels to one of my favorite movies from the early 70’s.

Confession: In the airport I wanted a paperback to read, so I grabbed Wreck, a novel by Catherine Newman set in Western Massachusetts. I picked it up mostly because I liked that it was set where I did residency, the book had small chapters -perfect for quick reads before bed, and good reviews. I have not read anything by Catherine Newman before, but I think I may just work through her books next.

On the Calendar

• Hospital-to-Home — open now. Enhanced care for the first 30 days after a discharge.

• Employer and insurance conversations — I've started talking with third-party administrators, the outfits that actually administer self-funded employer health plans. If that goes where I think it can, a small business could offer direct care as a real benefit rather than an out-of-pocket extra, and eventually individual plans could sit alongside a membership instead of competing with it. Early days. No announcement. But it's the direction.

• Ask Dr. Brian, Episode 2 — Available on YouTube Now.

• Culinary medicine sessions — still in development for early 2027.

• October Office Hours: By Appointment Only

• Discovery Call - book here

• Membership info & pricing - check out the new webpage

And as always: reply to this email - I read every one.

Reader Challenge 

The walking report

Last month I told you I was building a walking habit, and that the number stuck in my head was thirty minutes a day. That number isn't arbitrary, though it's softer than most people think. The federal guidelines ask for 150 to 300 minutes of moderate activity a week — thirty minutes five days a week only just clears the floor. And the current edition dropped the old rule that activity had to come in blocks of at least ten minutes; the finding was that total volume is what's related to the health benefits, and bouts of a prescribed length aren't essential. (Physical Activity Guidelines for Americans, 2nd edition, U.S. Department of Health and Human Services, 2018.)

Two walks changed that.

The first one, I was running behind and the window I'd set aside had nearly closed. I figured I'd get maybe fifteen minutes, so I just went. What I actually got was a clear head and a decision I'd been chewing on all morning — and when I looked down, I'd walked thirty minutes anyway. The guidelines had already told me a short walk would have counted. I just hadn't believed it. The walk wasn't the point. Leaving was.

The second came from Whitefish, where I lived for a couple of years and where everyone says hello when they pass you on the street. I started doing it here: actual eye contact, which in a city is mildly against the rules, then a smile and a good morning. Two mornings, somebody stopped and talked — helped that I was near the new coffee shop in the park. I liked it more than I expected to.

I also lost the device-free morning I'd built the month before. It slipped away almost without my noticing.

So my goal for next month is none. I'm not adding anything — I'm going to make walking boring and automatic, and rebuild the morning I let go. There's a model of behavior change that runs precontemplation, contemplation, action, maintenance, relapse, and relapse isn't the part where you failed. It's one of the stages. The failure is not noticing, or noticing and not adjusting.

If you've been carrying something from the last two months, my suggestion is the same one I'm giving myself: don't add. Reinforce. I'll report back.

Know someone who needs this?

Forward this email. Word-of-mouth is how a practice like this gets built. No mass advertising. No gimmicks. If you’re receiving this email, you know me and the level of care I give to my members. That’s the best advertisement I have.