DPCA Articles

There are many labs and tests that can be done without sending samples to an outside lab or pathology group:

• Urine dipstick
• Rapid strep, mono, influenza A/B, covid
• Urine pregnancy testing
• POC INR, Hgb A1c
• Fingerstick glucose
• Stool FIT testing or fecal occult blood
• Urine drug screening cups

If you are doing any testing on any body fluid or tissue, you will need to have a Clinical Laboratory Improvement Amendments (CLIA) Waiver. Some states have specific applications and requirements for CLIA certification, so speak to a DPC doctor in your state for guidance. Once you have applied for, paid for, and received your CLIA waiver, there are a whole host of tests you can offer within your practice. These tests can be easily obtained through any major medical supply wholesaler (and will often note that the test is “CLIA Waived” or not). In some states, in-office testing is allowed without major regulatory oversight with the assumption that you are doing it correctly, of course. Some states require “competence certification” so, once again, speak with a DPC doctor in your state. The onus is on you, and your license, to ensure that anyone performing this in-house testing is properly trained on the full instructions for each test.

For a high-level overview of arranging labs outside of your practice, see this article on Arranging Client Billing Labs.

Integral to any relationship is good communication; your relationship with your patients is no different. Before picking your software and platform for communication first decide your priorities for communicating with patients:

• Will you allow texting with patients? If so, during what hours? And for what concerns?
• Will you allow direct emailing with patients? If so, for what concerns?
• Will you utilize a patient portal for messaging with patients?

Additionally, there is one big law that governs communications with patients: The Health Insurance Portability and Accountability Act (or: HIPAA).

• The Department of Health and Human Services has information about patients exercising individual choice regarding communication linked here.
• DPC Frontier discusses the nuance of HIPAA in the context of running your DPC practice.

Understandably, HIPAA is a complex subject that likely warrants consultation with your attorney.

Once you get past the legal hurdles and decide your communication preferences, there are many software vendors that help you communicate with patients.

• Spruce
• AtlasMD
• Google Suite (email, forms)
• + various other secure messaging apps -- just do an online search to see what’s out there!

Once you decide how you are going to communicate, you need to educate your patients.

One of the biggest benefits of direct primary care is the fact that it removes episodic, transactional billing and provides a more fluid, easy-to-administer monthly fee.

Several vendors can assist in the monthly billing process. The ones that can cater to the DPC marketplace are:

• AtlasMD (EHR)
• Hint Health
• Twin Oaks
• Cerbo (previously MD-HQ) (EHR)
• Square
• And many more…

Beyond the monthly billing, other items require billing your patient. A far-from-comprehensive list may include:

• Labs*
• Imaging*
• Medications (see DPC Frontier for state-by-state regulations)
• Pathology* (see DPC Frontier for state-by-state regulations)
• Durable medical equipment
• Medical supplies (i.e. stitches, casting, etc.)
• Enrollment fees, after-hours visit charges, etc.

*There is a concept, called “client billing” where a vendor bills you, the practice, and you pass the charge on to the patient. Many vendors use this setup to offer your practice -- and subsequently, your patients -- below-list-price prices. Other vendors offer direct, patient billing. There are pluses and minuses to each setup.

When a patient needs to get lab work outside the scope of your practice’s in-house capabilities, there are several options to consider:

• CLIENT-BILLING: This is what most DPC practices have in place with a lab company to ensure transparent rates and avoidance of insurance hassles. This is effectively a “passthrough” where the lab company bills the practice rather than the individual patient. Client billing is allowed in most states, but a few have restrictions. Setting up this option for your patients, insured or not, is typically the most affordable option for your patients. (See article Arranging Client Bill Labs for more information).
• LOCAL LAB WITH INSURANCE: If a patient has an insurance plan, you can give them an order and visit a local lab that will bill their insurance as usual. This process can, of course, be filled with many pitfalls and caveats for the patient and doctor. For example, the patient and physician may not know which labs are in-network or out-of-network. Some insurances may have limitations on which labs can be drawn or how often. And there may be unexpected costs associated with this option. Additionally, the physician will be required to supply diagnostic information not required for the other options (ICD 10 codes). If a patient chooses this option, the best advice is to urge caution and keep expectations low.
• LOCAL LAB WITHOUT INSURANCE: Sending a patient to a lab without insurance is likely to stick them with a bill with “chargemaster” (3-10x insurance) rates. This is not advisable unless the lab company has a transparent, “self-pay” option in place (fairly rare).
• ONLINE LAB SERVICE: Many online companies will sell labs, often without a physician’s order, directly to patients (for example Ulta Labs). Many of these companies are basically resellers who use a lab company (e.g. Quest or LabCorp) to perform the actual lab and deliver results to the patient. On average these will be more expensive than client-bill rates, but less than chargemaster rates for uninsured patients.

A question asked frequently within the DPC community is whether or not you can successfully open a direct primary care practice in your own home.  It is a natural question to ask since, in many ways, the DPC model is ‘going back to the future.’  We are trying to recapture the spirit of the old-time family doctors who cared for many of us and our families in generations past.  Many of these physicians had offices attached to their homes and were very successful.  The question is whether or not that can be done today.

There are a small handful of DPC physicians who are practicing in a home office and are very happy doing so.  There are several pros and cons, and many factors to consider before going down this road.  We do our best to outline them here.

Without a doubt, the first thing to examine is how would having a practice within your own house affect your family?  If you have a spouse/significant other, are they on board with this concept?  Will working out of your home improve your relationship because you may be home more because you have no commute?  Will it hurt it because you have a hard time walking away from work and respecting home/work boundaries?  Is your spouse/partner going to work in the practice with you?  Some love the idea of just going down the hall to go to work and being able to have lunch in their own kitchen or a nap in their own bed.  On the other hand, some prefer clear delineation between home life and work-life to promote balance.

If you have children, how will this affect them?  There is a definite advantage to working out of your home if you have young children, especially if both parents work in the practice.  It would allow you to check in on the children throughout the day.  If a child is home from school sick, it is easy to keep an eye on them without having to take a day off.  Older patients often love to see the doctor’s children coming in and out of the office.  It promotes a sense of family in your primary care practice.  On the flip side, some physicians prefer not to have their children underfoot, and to maintain boundaries between patients and their private lives.  If the children tend to be noisy, that can irritate you and the patients. There are also considerations in terms of whether or not you want to have your children potentially interacting with strangers in your front yard.  It is also important to have you think about keeping your front yard free of loose toys, bicycles, etc.  It detracts from a professional appearance and can create tripping hazards.  Also, your pediatric patients might help themselves to play with your children’s toys, which may not be ideal.

The second issue to research is whether or not local town ordinances will permit you to run a medical office out of your home.  In our experience, the codes often vary widely from one town to another.  In many cases, home offices are allowed by the municipality if they do not take up more than a certain percentage of the house’s square footage (i.e. 20-25%).  Some towns might restrict the absolute amount of square footage that is used for the office space.  It is not uncommon in cities and suburbs to require that the business have a certain amount of off-street parking, which is usually based on the square footage of the business.  There may also be constraints on signage in order to maintain the residential feel of the neighborhood.  Some towns also have a cap on how many employees can work in your office who do not reside in the home.

If after doing this research, you find that you would not meet your town’s criteria for being considered a home office within a residential area, you might have to investigate what it would entail to have your property rezoned.  Some localities recognize a residential/professional designation, which is ideal for what you would need.  It means that a home can be used for either purpose at any time.  If your town does not have this option, you might have to look into petitioning to have your property rezoned for business purposes.  Depending on whether or not your town hall is business-friendly or not will determine how difficult this process might be.  In order to test the water, you might want to speak to your local code enforcement or planning department to see what they require.  Some towns will allow a single parcel to be rezoned to accommodate a business, but some would require that a whole group of them convert.  The process would require a formal application, meetings with the planning committee and town council, as well as soliciting input from your neighbors regarding their concerns about the proposed zone change.  It is sometimes beneficial to discuss the process with an attorney with experience in this area.  If you need to go through this process, it can take several weeks or months, so please factor that into your plans.

It is important to check with your homeowner’s insurance company to see if you will need to add a rider to your current policy to allow for a home business.  There is a chance that they cannot cover you at all, at which point you would need to talk with a broker about a new policy.  This may be an inconvenience, but not the end of the world.

The optimal arrangement for a home office is to have a space that is completely distinct from your living area, with a separate entrance, which is clearly marked so that patients do not go to the wrong door.  As a home office, there is a good chance that you will not need to be ADA compliant, but it is still a good idea, if possible, to be as handicapped accessible as possible.  You might want to consider a ramp if the door is not at ground level.   If your office space needs structural renovations, you may need a permit and certificate of occupancy from your town.  You can expect a visit from your local fire department to be sure that you have fire extinguishers, emergency lights, and fire alarms in the areas open to the public.  We will not discuss office design or space requirements here because every practice and physician is unique.  

The financial advantages to a home office are many.  You should talk with your accountant for formal advice because there are many different approaches and each may have its own advantages.  Some examples given by one physician who practices out of his home are: it is legitimate for you as a homeowner to charge the practice rent.  This will allow you to defray a portion, if not all, of the cost of your mortgage as a business expense.  In order to do this, you should have a formal lease.  You may be able to pay some of your utility bills as a business expense.  You may also be able to declare a portion of your home improvements, landscaping, and other expenses and supplies necessary to maintain a professional appearance to your building.  (Please consult your accountant for formal guidance.)

Frequently, the question is asked about practicing medicine out of your home is about patient boundaries.  This generally is not as big an issue as one might suspect.  The key to success is to clearly establish boundaries early on.  If the office entrance is clearly marked, it is not likely that patients will be knocking on your front door.  Patients tend to be extremely respectful of your private time.  Occasionally, patients may broach the subject about dropping by to see you after hours but frame it as a joke to feel you out.  It may just be a joke, but it is usually best to make it clear, in a friendly way, what your boundaries and expectations of privacy are.  It may sometimes be a challenge to enjoy a day off during the week and be in your front yard and have a patient stop by unexpectedly to ask a question, pick up a refill, etc.  In most cases, simply letting a patient know that you are enjoying private time and that it would be better if they call before coming over is perfectly fine.  The same applies to pharmaceutical representatives.  Realistically, the best way to avoid interactions such as this is to not be visible during personal time taken off during your usual business hours.  Stay in the back yard, in the house, or away from home.

In summary, there are many things to consider and research before opening your medical practice in a home office.  It is a unique situation with many advantages and a few caveats.  It may not be a good fit for everyone, but for the right physician and their family, it can be a fantastic arrangement.

During your transition to your DPC, you will want to notify your existing patients about the change. If you have a non-solicitation clause in your agreement, you have to be careful how you do this. Before announcing your departure, there are some ways to circumnavigate this and maintain contact with patients without breaking your non-compete clause. Check your contract - does your non-compete clause include email addresses and social media connections?

CONNECT WITH YOUR PATIENTS ONLINE BEFORE YOUR ANNOUNCEMENT:

• Open social media pages on all platforms and “friend” your patients from those (check your contract, some employers have shut down social media networking with patients)
• Start your website as a physician (not the name of your new DPC….yet)
• Consider posting some blog posts about health topics on your website/blog
• Ask friends to share your posts so that patients can see them too
• Join all the local community groups on social media with your full name and participate in some discussions. Patients will start to take notice that you are there.

EMPLOYED PHYSICIANS - TRY TO NEGOTIATE NON-SOLICITATION CLAUSE:

Most employers may restrict your ability to notify patients about a new (competing) practice. However, that is not universally true. It’s best to have a conversation with your employer to get the best terms possible.

Consider using the discussion point that your DPC practice will be totally different from your current FFS practice. You can argue that because the new practice will be so different you won’t be competing against each other. Each situation will have different results depending on the hospital and administrators. The best-case scenario is to obtain the contact information (mailing address and emails) of all of your patients. You may want to prepare for a negative outcome, that they say no to patient solicitation. Before you announce your departure, there are some ways to circumnavigate this and maintain contact with patients without breaking your non-compete clause. Check your contract - does your non-compete clause include email addresses and social media connections?

IF SOLICITATION IS PERMITTED - ANNOUNCEMENT(S)

• HOW MANY? Send at least 2 notifications (letters, emails, or other) to create some anticipation and build-up to opening your DPC practice. This can be a great marketing strategy and ease potential shock patients.
• CONTENT: Your announcement should include, and likely start, with your “why.” Let patients know the reasons why you have decided to switch to DPC, namely, to provide better care to them! This will help incite an emotional and human response from patients. At the end of this letter, create some anticipation, with a teaser and sign-off with “stay tuned” or “more information coming soon.”
• FOLLOW UP: Your subsequent announcements should give more detailed information on your DPC practice, including timeline, website, how to sign up, and contact information. You can also use this letter to invite each of them to an informational meeting or town hall to help answer their questions about DPC.

MAILING LETTER(S)? It can be expensive to send letters to each patient or family when you have thousands of patients, so most physicians elect to only send one letter. You can use a local mailing service or you can recruit family, kids, or friends to help you stuff envelopes. This can be very time-consuming but can save you money on start-up costs if you have the time. Conversely, if you have enough money to use a service, this can save you significant frustration and time. Remember email is much more affordable, but at least one mailing would be appropriate. To invite patients to events you could consider postcard type mailing which is much more affordable.

SPREADING THE WORD IF YOUR NO SOLICITATION IS IRONCLAD

• Continue to post health blog posts and share them on all your social media
• Monitor your community social media groups and if patients post asking about where you went, recruit a good friend to answer the post with your details
• Get involved. Offer to give a talk at your local business association/community center/church on medical topics. Give your new cards out and ask your community to spread the word.
• Solicit newspaper or television media to write an article or do a TV news piece on your practice. Share it on your social media and ask friends and family to do the same.
• The power of social media reaches far beyond the non-compete. As long as the patient finds you, and not the other way around, your non-compete patient solicitation clause has not been violated.

NON-COMPETE RADIUS:

• Patients will travel for medical care from their physician that they trust, especially when DPC allows care to be done easily through telemedicine.
• Find the location that suits you best. Take a 2-year sublet or lease. Once your non-compete is up, you can decide to move your DPC location closer to your original patient panel. Who knows, maybe your new location will suit you better.

SAMPLE NOTIFICATION AND TRANSITION LETTERS (DPCA members only)

1. Transitioning to DPC from Private Practice Letter - Written by Debbie Sutcliffe, MD (members only)
2. Transitioning to DPC from Employed Practice Letter - Written by Kissi Blackwell, MD (members only)

As of 2020, roughly 400 physicians commit suicide annually. More than 40% of primary care physicians’ time, by some estimates, is taken up with non-clinical activities. Burnout and moral injury are oft-discussed phenomena regarding the physical and emotional toll practicing medicine has taken on physicians. Put simply: current healthcare constructs fail to provide a therapeutic environment for the patient and physician and, most importantly, for the physician-patient relationship. Direct Primary Care (DPC) is one practice model that focuses on the physician-patient relationship where the incentives of both parties are aligned. The chasm between being an employed physician in a traditional health care setting and going out on your own to open your own small medical practice can seem exceptionally vast. However, many physicians are returning to solo or small group independent practice and are sharing their experiences on how to do so successfully. DPC restores physician autonomy, affords the same and next-day access, and is empowering primary care physicians to remain inspired and empowered.

Why Dispense?

One of the best ways to bring value to your DPC membership is to dispense prescription medications out of your office. It saves patients time, energy, and (most of the time) money to get their prescriptions from your office. 

Physicians can currently dispense prescriptions out of their offices in 45 states. The rules and regulations for dispensing varies drastically by state. DPC Frontier which is managed by Phil Eskew DO, JD, MBA has an extensive listing of each and every state that he keeps track of.  (https://www.dpcfrontier.com/dispensing-medications). The five states that currently dont allow physician dispensing are NH, MA, NJ, TX, NY (even in these states there are some “emergency” situations where short term prescriptions can be dispensed. 

For the rest of the states, after you have complied with your state regulations, you should strongly consider providing this service. It is extremely valuable for a sick/acute patient to be able to get what they need at the visit rather than going to the pharmacy to wait for an hour or more while in pain or ill. 

Similarly, dispensing chronic medications is valuable for patients. Many DPC offices will buy drugs in bulk just like a pharmacy and sell them at very little or no profit. Patients will often save enough money on several prescriptions to pay for most or all of the DPC membership fee. (example: lisinopril is currently 5 cents/pill. 100 of them would only be $5). This provides VALUE to your membership. Many of your patients would rather spend their money with YOU to support your small business and you. Dispensing medications allows you to keep better track of compliance as well. 

Also if you get your system streamlined, you provide ease of ordering and picking up medications. Patients will communicate by text, call, email or any of the above to request refills. Most offices will fill non urgent meds within 1-2 days. Usually their software or EMR tracks the meds and billing allowing patients to just put the meds on their account. This makes it easy to just come in and pick them up without long lines and wait times at a pharmacy. Some offices will buy or add some sort of “lockbox” on the outside of their building for after-hours pickup when necessary. 

How to Dispense

There are multiple online distributors that will sell meds (and bottles) in bulk and deliver them to your office. Andameds, Bonita, Henry Schein to name a few. With most of these suppliers, you can create an account and pay weekly or monthly for the supplies you buy. 

Something to consider is what pill counts to order. If you buy in bottles of 1000s then you or your staff must plan a way to count out the right amount of pills. You may need to buy a pill counter (https://rxcount.com/rx-4/. They run about $2500). Another option is to buy in 90 or 100 count bottles. Then you dont have to count. You do need to be aware of your state law on the type of container needed to dispense. Most have to be child proof.

Prescriptions also need to be labeled. You’ll need a label printer. (Dymo and Brother are a couple of the label printer companies to consider). Connecting the printers to your computers requires a little bit of tech know-how. Most of the inventory tracking and managing will populate the labels with the information. The majority of EMRs that are used in the DPC community do the inventory and billing directly, but there are other software programs that cover this as well if needed. 

A few docs also team up or hire a local pharmacy or pharmacist to manage the dispensing. The main concern about this is making sure that they provide good value to the patients. Otherwise it would be the same as any other pharmacy they already have access to.

Deciding how you wish to handle Medicare is a huge step for those entering DPC. There are several excellent resources on how to opt out of Medicare and the consequences of doing so.

• Dr. Phil Eskew’s DPC Frontier has the go-to resource for legal issues on this matter.
• To learn how to opt out of Medicare, watch this video.

The more important discussion here is why and when to opt out of Medicare. In order to offer full-scope DPC for all patients, you must eventually opt out of Medicare. Until you opt out you either cannot see Medicare patients, or you must bill Medicare for your services. Some small loopholes allow for billing Medicare patients for non-covered medical services, which is a tactic utilized by many concierge practices, but if you wish to consider this you must speak with an attorney to ensure you are set up correctly.

Many physicians starting out worry that they will struggle to enroll Medicare patients into their DPC, so they choose to remain opted-in during start-up. However, if your end goal is to be full-DPC, it may not be a great plan long term to do this as you will eventually have to make the transition, and it may be harder to explain the change to established patients than it would have been to enroll Medicare patients directly into DPC from the beginning.

When deciding the right time for you to opt out, one of the major decisions is whether you anticipate moonlighting. Most moonlighting opportunities require you to be opted-in. Medicare does not allow you to opt-in at one location but opt out at another. Thus if moonlighting will be important for you financially, you may choose to delay opting out. (See this Member Only article Moonlighting and Side Hustles for more information)

You should also realize that your opt-out is effective for 2 years and will automatically renew every 2 years unless you apply to be reinstated. Effectively, once you decide to opt-out you should assume you are opted-out for 2 years because opting back in within the 2 years is extremely difficult and rarely successful.

Finally, if you have been credentialed with Medicare as a private entity, you will likely only be able to opt-out once per quarter (Jan 1, April 1, July 1, and Oct 1) so you must plan accordingly. If you miss the deadline, you are stuck until the next quarter and you cannot accept payment from Medicare patients. In some areas, if you have only been credentialed as part of a larger organization, this limitation does not apply to you. And the opt-out process does have some regional variation, so speak with an attorney or DPC mentor near you to help you determine whether these deadlines are likely to apply to you, and how to opt-out in your region.

Non-solicitation clauses in employed practice can be difficult to navigate when you are trying to transition into DPC. Try to find out exactly what the clause states and how restrictive it is. If you are able to let the patient know you are leaving, but not where you are going, you may be able to simply hand them your new DPC business card and direct them to your website for enrollment. In these cases, it is especially important that you have your cards, flyers, and website already created, so it is very simple for patients to find you on their own.

Some clauses are very restrictive and will not allow you to let patients know that you are leaving. In this case, there are opportunities to create a personal brand via social media, podcasting, or blogging. While planning and preparing for your transition to DPC, you can share these channels and content with your patient so they can start following you on your journey. This way, you can eventually let them all know where you will be in a more passive form.

Know the laws and the board regulations in your state. In Texas, for example, you are required to send a letter to all patients you have seen within the last 2 years and notify them of your departure. You can allow the employer to do this for you but since the physician is ultimately responsible, you can elect to do this yourself instead. For physicians in Texas, this is a prime opportunity to alert patients of their new location and practice model. They may even want to invite patients to a town hall type meeting explaining the workings of the new practice inside the text of the letter.

Whether you are employed or self-employed, there are lots of ways you can market to your existing patients while you are transitioning to DPC.

If you are employed, check your employment contract for clauses that may hinder or prohibit the solicitation of existing patients. Read Leaving an Employer for more information.

First and foremost, BE READY!

• Before you start talking about your new practice have a few things in place, including contact information, website, and some practice (business) basics. Read this article to learn more about Branding and Marketing[UPDATE LINK].
• Create and share some print marketing: business cards, flyers, brochures, etc.
• Consider possibly waiving enrollment fees or for patients that sign up prior to your opening date.
• Create a letter for patients to give notice of your transition. Consider adding an event invitation to the letter, such as a town hall event.

Pre-enrollment

• Embed a link to your enrollment/EMR inside your website to pre-enroll patients prior to your opening date.

Once you have everything ready

• Use the time between announcing your transition and your opening date to market to EVERY SINGLE patient. Use each patient visit as a marketing opportunity and practice your 1-minute elevator speech.
• Hand out flyers and business cards during patient visits and direct each patient to your website for immediate enrollment. You might consider letting them know that enrollment will be limited.
• Consider holding one or more events where you explain your practice, answer questions, and enroll patients
• Find networking events, such as health fairs or other community events. You might also consider small business networking, such as BNI, Rotary Club, Lion’s Club, and Chamber of Commerce.

Called “dunning,” many businesses find themselves chasing after unpaid bills. Even in direct primary care, with the streamlined monthly billing, you will find that a certain percentage of charges simply won’t go through automatically for a variety of reasons (think: stolen cards, lost cards, expired cars, insufficient funds in a pre-paid or HSA card, etc.).

For those whose payments don’t go through automatically, a systematic process will both create clarity for your staff and patients and will also allow you to operate in a business-like fashion without letting your big, DPC heart get in the way.

Here is a sample process:

From Allison Edwards, MD | Kansas City Direct Primary Care

Clinic-Triggered Cancellation for Nonpayment (using AtlasMD)

All monthly membership payments to the clinic must be paid via automatic payment (it’s in the contract). If a patient’s auto-pay on the 1st or 5th (we only allow the 1st or 5th) fails, the following ensues:

Notification (numbers indicate days from failed payment -- though we usually start this process on the 5th of the month):

• 0: Each failed payment triggers an automatic email from AtlasMD.
• 5: Names are added to the “Failed Payments” list (a living GDoc) on the 5th (or next business day) of the failed payments; each of these members is called or texted by the front staff. Results of the communication are noted on the list.
• 15: Any balances that remain unpaid after the 15th receive a standard letter via US mail and an identical email noting their failed payment and impending 30-day termination.
• 30 or 31: the auto-payment system tries to charge the patient again at the start of the new month (for last month’s balance + current month’s fee). As detailed above, on the 5th the list is updated with new failed payments, and a note is made of the payments that have failed 2 months in a row. Just as before, an automatic email is triggered by AtlasMD notifying the patient of this (second) failed charge.
• 45: A final letter of termination due to nonpayment is created. The letter is then sent to their primary mailing address & also sent as an attachment to their email address.

Determining the remaining balance & ending the membership:

• Remaining balance = the previous month’s fee + prorated half of the current month’s fee (total = 45 days’ worth of membership following their first failed payment). Proration = $(12*(monthly membership fee)/365)*(15).
• End the subscription charge in their chart & delete the current month’s full charge.
• Add prorated fee, as above, as a miscellaneous charge and label it “Medical Services - (month)” then select “Apply charge to the current invoice?” and “Add payment for this charge?” to (try to) run the card for the remaining balance.

Assigning all files & messages:

• In the files inbox in AtlasMD, make sure that all files & messages relevant to this patient are assigned to them (including the letter just created).

Archiving the patient:

• From the billing section of the patient’s chart, the option to “Add to collections” is selected from the cogwheel. Note: we do not actually send the patient to collections, this is just a designation to separate out those who have a remaining balance with us at the end of their membership.

Adding to the Master Status Report

• We track -- as best we can -- the reasons why people leave the practice. The person archiving every patient will add the patient’s name, enrollment details, etc. to the most current Master Status Report.

When starting your own business/practice one of the more exciting aspects of business ownership is taking advantage of the many tax write-offs available to you. It can be easy to get carried away and get yourself in trouble (audited). Knowing what you can and what you should write-off are keys to avoiding a visit from the IRS. As my accountant told me early on in my practice “pigs get fat, but hogs get slaughtered.” Just like eating cupcakes, moderation is key. In recent years, tax laws are changing constantly and are not permanent. Some of the options listed here are set to expire in 2025. Having a good CPA you meet with regularly is necessary to stay on top of everything. Another thing to remember is that you do not need to feel guilty for avoiding paying taxes. The tax incentives and write-offs the government creates exist to help incentivize business creation and growth, in turn, improving the economy. 

Self-employment tax

• You may be asking, “wait a minute, I thought this was an article on write-offs?? A tax as a tax write-off?” Well, this one is ​​a little confusing to me as well, but as a business owner, you have to pay an additional 15.3% tax on the salary you pay yourself, on top of your normal tax bracket. If you were an employee, you would pay half and your employer would pay half. The good news is that you can deduct half of the self-employment tax from your net income when you calculate your income tax bracket. As a business owner, you can help minimize this tax though by paying yourself the lowest salary you can while taking the remainder of your pay through owner draws (if you are filed as an S-corp). The catch is that you have to pay yourself what you would pay someone else to do your current job duties. The IRS may let you get away with not paying yourself a salary for several years, but it will raise red flags if you pay yourself via owner draws for too long. A CPA can help guide you when you need to start taking a salary. 

Home office

• In my opinion, this one can be tricky and maybe more trouble than it’s worth. There is the standard and the simplified method. Your home office space has to only be used for your business. It has to be used “exclusively and on a regular basis, as your principal place of business.” It cannot be larger than 300 square feet. With the standard method, you can deduct the percentage of your expenses for the house. Including utilities, home depreciation, etc. The simplified version allows you to deduct $5/sq ft or up to $1500. If you do decide to set up a home office you can also reimburse yourself for mileage driven from your home office to your main office, and this is not countable as taxable income. I would run this by your CPA first as the “principal place of business” line would likely make it hard for most people to qualify. 

Clothing

• I got into trouble with my CPA on this one when I first started. I was attempting to write off any clothes I bought that I MIGHT wear to the office. My CPA pointed out that I could only deduct clothes that I would ONLY wear to the office like scrubs. So, go ahead and buy those new Apple Bottom jeans but don’t try and write them off. 

Meals

• For now, until the end of 2022 you can deduct 100% of a meal as a business expense. You have to be traveling for business, at a conference or entertaining a client. Traditionally you could only deduct 50% of the cost of the meal. When I first started my practice I tried to write off every meal I ate while at work, even if I was by myself, unfortunately that is not a deductible meal. 

Health insurance

• If your spouse is employed and you do not qualify for their plan, you can deduct all health/dental insurance premiums. If you pay for your spouse’s and kids’ plans as well, you can also deduct their premiums. 

Cars

• This is one I tried early on in my practice and found it too involved to be worth it at the time. You have to keep track of mileage and purpose for each trip. I even used an app called MileIQ that automatically tracked each trip. The app made it much easier, but even with it, I had a hard time keeping up. If you are good with tracking/categorizing every time you drive, it can be a significant deduction. You can basically deduct the percentage of the time the car was driven for business-related purposes throughout the year. If you do not qualify for a home office, then the only times you drive from your home to a coffee/lunch meeting, business trip, etc would count. There are some pretty risky ways to be able to write off the entire cost of the vehicle, but as my CPA told me, you’d have around a 100% chance of getting audited. If you’re curious about how this would work, you would buy the vehicle in December to make it easier to ONLY use it for business-related expenses (i.e. leave it parked at the clinic). Then, when you are filing your taxes for that year, you can take the depreciation deduction all within that year and deduct 100% of the cost of the vehicle. If it’s looking like you may owe a lot of taxes in a given year, this may not be a bad strategy, but have all of your i’s dotted and t’s crossed for that audit that is coming. 

Travel

• The main things you can deduct while traveling for business is transportation to, from and at your destination, lodging and meals. Transportation and lodging can be deducted 100% but meals are 50%. The trip must last longer than an ordinary workday and outside the city where your business is located. Make sure you have the business purpose of your trip planned ahead of time. If you are combining a business trip with a vacation make sure you deduct the percentage of the trip that was dedicated to business. 

Event/party at your house

• If you want to host a Christmas party or another company get-together at your house, you can actually pay yourself similar to what you would have to pay to rent out another facility. This is a double-whammy in that you get paid and can write off that expense under the business.

Interest

• This may not be a deduction you want if you can avoid it, but if you have any bank loans, lines of credit, credit card interest you can deduct the interest paid on it. You cannot deduct the full loan payment. However, if it is a loan for equipment or a vehicle, then the combo of interest paid and depreciation typically is similar to the total loan payment each year.

Transfer of, normally, personal expenses to the business

• This is not a write-off per se but it can help decrease your taxable income. Here is a list of several examples:
  • Charging your electric vehicle at your office which allows to pay for your “fuel” through your electric bill at the office. 
  • Hiring your kids to do jobs they are capable of doing like cleaning, then they can contribute that to their college funds. You can also use your kids as models and use their pictures on your website or social media. You can pay each kid up to $6000/year without having to pay income tax. 
  • Contribution to a retirement plan. You need to be saving for retirement anyways!

If you are currently employed by a clinic or hospital, prior to leaving, you’ll need to consider a few things, including your contractual obligations.

CONTRACT: Hopefully, you have a copy of any contract you signed, but if not, you have to ask your employer for a copy of it. Once you have the contract, you should review it with an attorney to find any potential legal problems in leaving or starting your new DPC clinic. A few specific issues often come up:

• NOTICE OF TERMINATION PERIOD: Most contracts will contain a minimum length of notice for termination; 30-90 days are most common. You need to know that specific time to plan your leave.
• NON-COMPETE CLAUSE: Many employment contracts include a clause that restricts a physician from practicing elsewhere after leaving. These are called “non-competes” and restrictions can include a scope of practice, duration, and geographic locations (i.e. not within a 100-mile radius).

In some situations and states, non-compete clauses can be difficult to enforce. For a review of this, read this article from DPC Frontier. Regardless, these clauses are often used by an employer to scare a physician from leaving or starting a business that poses competition.

• NON-SOLICITATION: Some contracts may prohibit you from directly marketing your (pending) new practice to an existing patient. Obviously, this can be difficult to enforce, but best to understand the terms and what is permitted.

Regardless of your contractual obligation, it’s always best to sit down with your employer (clinic owner, manager, administrator, or other boss(es)) and have a discussion. Leaving on amicable terms when possible is best.

Review this article on terminating insurance contracts.

Choosing a name for your new DPC clinic may seem trivial but it can be nerve racking for many. Obviously, you want something that sounds catchy and really shares your DPC passion but also is unique. Easy right? Here are some starter tips to get you thinking.

First, start brainstorming with your friends and family. Think about why you’re doing DPC? What is your passion? And just so you know, “Screw The System” is not a good name for your clinic. What about your own personal name, is there something there you can use? Like Gold Direct Care or NeuCare. Think about your community or location, is there something there you can use? Like Hometown Direct Care or Bluegrass Wellness. Write ideas down. Say them out loud. Do they sound good out loud? Be careful about initials, Applewood South Sound Clinic would not be good (let me know when you get that). This example also shows that a name can get too long. Consider searching the DPC Alliance directory for names to get some ideas. And if you are really loaded with cash or crunched for time there are crowdsourcing sites like squadhelp.com that you can pay to help you come up with a cool name.

Ok, you got a name. You think it’s the total bad mama jama. A huge weight has been lifted off your shoulders, and then you go to search for the name among the thousands of clinics, or purchase the name for a trademark or website, etc, and ARRRRRGGGG. It’s taken. So, that is why I say make a list because the next step is to take the list of all the names you came up with and search out your new name on the ole interwebs. Is your name taken already? Just do a Google search. What pops up? Does your search bring up a list of hate groups in Montana? Well, not good. Does your name mean “loser” in French? Again, not good. Check other search engines too.

Next, search your name on the GoDaddy site or another domain purchase site. Can you buy your domain? Just because you don’t see you name come up on a Google search doesn’t me you can buy it. Some names especially some with the words health or care or wellness in them will be premium domains. Is the domain name available and reasonably priced? No debate here on .com or .net or .health domains. Pick one you like and can afford knowing that .com are just way more common. Now check on social media sites like Facebook, twitter, Instagram or LinkedIn? Can you use your name there? You’ll need those later for marketing, though your exact name is not as critical for those.

Finally, you should check your Secretary of State’s website for companies in your state with the same or similar name? If you want to have an LLC or similar in your state you need the name to be available. Also, if you have any ambitions to grow you DPC business into an empire maybe you should consider doing a trademark search. It takes a unique name to be trademarked. Along this line, if you may expand locations or add additional services like aesthetics or counseling would your name still fit? You should think bigger than you are right now.

Your office name is important but it shouldn’t plague you with regret. We hope these simple tips will help guide you to a great clinic name. Be sure to share you name ideas with your Alliance colleagues and get their reviews too. Now, get busy.

One of the greatest benefits of the DPC movement is the collaboration among DPC physicians. Most independent physicians want to help other physicians be successful. Mentorship and the culture of “rising tides raise all ships” has been fundamental to medical education throughout the history of medicine. A good mentor is someone who is enthusiastically willing to share their knowledge and expertise, provides guidance and constructive feedback, and is successful in their own DPC practice.

Resources for Finding a Mentor

Below are two websites which have DPC mappers. Search for DPC clinics in your state and close to you.

• DPC Alliance directory: DPC Alliance Members- physician only
• DPC Frontier mapper: Includes physicians and mid-level (NP/PA), Concierge practices, Corporate DPC practices

You can also do an internet search for DPC clinics in your state and close to you (ie google, duckduckgo, etc).

Social Media:

DPC Alliance Facebook Group

Join online DPC social media groups. There are many state or regional DPC Facebook pages which are great resources to find those around you. Use the search option to find posts about the questions that you have. Post your own questions. Use the files tab to access free resources posted by other physicians. Pay it forward by adding your resources as you build them.

You may find a story from an established DPC physician that resonates with you - for example, a transition practice, a part-time practice, specific practice niches. Do you want to build a practice with mainly uninsured? Mainly employees? Mainly pediatrics? All geriatrics? Do you want a micro practice, without employees? A large practice with multiple sites? Lots of procedures? Find doctors who have built a practice like what you want to do, and reach out to them. Email them and ask to set up a phone call/coffee/lunch date to hear more about their practice.

DPC Conferences:

The greatest value of an in-person conference is meeting like-minded physicians and developing relationships that will sustain you in a path less traveled. Virtual conferences are also helpful but it is more difficult to make those connections virtually. Consider signing up for at least one in-person DPC education event.

• DPC Alliance Masterminds (small group in-person learning with mentors)
• DPC Summit 
• DPC Nuts and Bolts
• Hint Summit

Questions:

• What should I ask of a DPC mentor?
  Ask informed questions - do your own research and read all the DPCA University resources before contacting them. Ask to hear their story. DO NOT ask all the basic questions that you can find answers for here - these physicians are glad to help, but they are grateful when a new prospective DPC physician has shown initiative and done basic DPC research prior to contacting them.
• How should I show appreciation for DPC mentorship?
  Most DPC physicians are passionate and excited about new DPC physicians jumping ship and starting practices near them. The best way to repay your DPC mentor is to PAY IT FORWARD by mentoring the next generation of DPC docs who start up after you.
• What can I expect from a long-term DPC mentor/mentee relationship?
  The DPC mentor-mentee relationship may become a mutually rewarding source of collaboration and support. Be open to sharing tips and tricks with local pricing, vaccines, and supplies, vacation coverage for each other. Be willing to listen when your mentor needs advice and encouragement.

Physicians transitioning from traditional, insurance-based practice have reported a wide spectrum of success in having existing patients sign up for their DPC practice--from 0-25% based on many factors. But, an average for many private practice doctors (transitioning their entire practice to DPC) is in the 5-15% of their panel in the first 6-12 months of DPC practice. Employed doctors, especially in a hospital or a large practice, have reported less.

Your success will be very dependent on how well you notify and market to your current patient population.

WHICH PATIENTS WILL FOLLOW? Many physicians have noted that the patients they thought would definitely follow them did not, and some of the ones they did not expect to follow them did. Market to every patient in the same way, as you never know who is really understanding the value of what you are doing.

BLOWBACK. You may experience some negative feedback from patients about your leaving traditional practice or not accepting their insurance plans. Expect some anger and frustration. You will have some patients that just will not understand why you are doing this and ones that feel you are probably just trying to make extra money. Try not to overwhelm yourself in appeasing these patients. Do your best to explain your “why” and move on. Many times, these patients come around later, especially when they find that continuing in traditional practice is not as great as they imagined. Word of mouth travels fast and your biggest supporters may actually sway these patients to come back to you, even years later. Do not engage angry patients. Be gentle and let them know that you understand that this model is not for everyone but that you feel it is right for you, your patients, and your family. (See Reaction From Patients for more information.)

Should I pay my staff as hourly employees or can I put them on salary?

The short answer is, “It depends.”

One would think this decision would be a fairly straightforward one, especially if both you and your staff are in agreement. It certainly would be easier to pay your staff members an agreed-upon salary every pay period. Doing this would avoid the need to track hours and submit them every week or two to your payroll company. If you have a good relationship with your employees and they are fine with it, it is hard to imagine that it would be a problem. Unfortunately, this is not the case.

As a small business owner, you must be careful not to run afoul of state and federal labor laws. They have concrete and sometimes not-so-concrete ways in determining if an employee should be considered an hourly employee or an “exempted” employee (someone who is paid a fixed salary). The simple definition of an hourly employee is someone who is paid a certain amount of money for every hour worked up to 40 hours per week, and who is eligible to receive that rate plus 50% for every hour, or fraction thereof, for time worked after 40 hours. A salaried employee, or an employee exempt from overtime pay rules, receives a fixed amount of compensation per pay period, regardless of hours worked.

You should know what the labor laws are in your state, as well as the federal regulations. If there is a discrepancy between the two, the rules that “protect the rights of the employee” will be the ones enforced.

One prerequisite to determine if someone is eligible to be on salary is that they must be paid at least $684 per week. (This amounts to $17.10 per hour or $35,568 per year.). If you are not paying an employee this amount, there is no need for further discussion.

One DPCA member found out during an audit by the U.S. Department of Labor that the hourly rate of pay is not the only consideration as to whether an employee could be on salary. According to that auditor, the role of the employee is taken into consideration as well. If an employee is a worker who does not have the authority to make important business decisions within a company, it is probably best to have them be hourly employees. If it is a local standard for other practices to pay similarly trained staff hourly and you choose to have a salaried arrangement with them, you could be seen as an outlier. This standard may seem a bit vague and open to interpretation, which is exactly why you should be careful not to give an auditor cause to potentially fine you. More guidance from the U.S. Department of Labor can be found here.

According to The Balance Small Business, “… federal law allows employers to consider some employees as being exempt from both minimum wage and overtime pay based on their job descriptions: executives, administrators, professionals, and outside salespeople.” If that description is accurate, then most nurses and medical assistants would probably fall outside that definition, but a practice manager could probably qualify.

The bottom line is that as a business owner, you should ere on the side of caution. If you are in doubt, it is probably best to consider staff members as hourly employees, even if you pay them for the exact same number of hours each pay period. Before you convert them to a salaried position, it might be best to check with your accountant or a human resources professional.

You’re about to hire someone -- maybe for the first time! Here are the first steps. If you’ve already hired and are looking for more nuanced articles relating to managing benefits, expectations, and/or firing an employee, see elsewhere in the database

Start with a job description. What do you need staff to do? What responsibilities will this employee have? The description lays out the basics like expectations, professionalism, dress, pay, hours, vacation, benefits -- and more. Remember that the more highly skilled the position hiring for, the more diligent and detailed you should be. Hiring front desk staff is crucial, but also essentially an unskilled position. As such you have a much larger pool of applicants. Vs hiring a new provider … this pool of applicants is much smaller and can be much more tricky.

• Determine the lowest level of training a person would need to fulfill that job.
• Determine the amount you can afford to spend; budget. This also will affect your pool of applicants. Especially the more skilled ones like new providers.

Create a job posting. There are many vendors available to list your job, each of which has a different price point:

• Indeed
• LinkedIn
• ZipRecruiter
• Craigslist
• Community message boards
• Word of mouth (Broadcast on social! Share over networking!)
• Word of mouth may also be the best because it’s easier to check references if you get them from people you know

Interview. Design interview questions (example questions found here) that are meaningful to you and your practice. Consider any/all of the following modalities of interview:

• Telephone: quick!
• Videoconference: an easy way to screen for tech-savviness
• In-person: more logistics and time-intensive, but can also be more revealing. Once again the more complex the position you’re hiring for the more in-depth your interviewing should be

Call references. Again, prepare for this with specific questions in mind. Expect that you can spend up to a week (sometimes indefinitely!) chasing down references.

Background checks. A quick online search will give you a few vendors to choose from.

Contract or no? There are different schools of thought; consult your attorney and accountant for guidance.

Consider ways to avoid a bad hire (and avoid paying costly unemployment):

• Clearly define a standard trial period of X days; if the hire is not a good fit, you can “not renew” their employment. Make X be a not insignificant amount of time. 2 weeks is NOT long enough. 2 or 3 months would not be unusual
• Consider a “trial day” or “trial week” to see if you’re a good fit -- and pay them for their time without a guarantee for future employment.

Remember OSHA! A good brief from DPC Frontier here and the federal government here.

Most of us would suggest that finding a “fit” for your practice is more important than finding the candidate with the most skills or training. To a large extent, you can always train unskilled staff in how you want them to do their job. What you can’t do well is change someone’s personality. So if they aren’t friendly or hospitable or patient or tough or fierce or passionate or whatever is important to you, your practice, and your milieu … DON’T hire that one.

As someone once said: hire slow, fire fast. Good luck!

Money is perhaps the number one consideration after your why that will ensure your DPC success. Prior to giving notice and quitting your present job, you must have a very strong grasp of your personal and professional financial situation. 

There are innumerable tools to help with financial planning, and a brief online search will open a world of financial self-help for you to explore.

At the least, you should consider addressing the following:

• Figure out your home budget. Or -- taking a step back -- look back at several months’ worth of spending and income. Where is your money going?
• Get your debt under control. Refinance, consolidate, and pay off credit cards.
• Come up with a plan to stop adding to your debt.
• Think about what financial resources you have: a benefactor? Access to free office space? A DPC doctor near you looking to partner? A spouse who has a stable income?
• Sell what you don’t need: switch neighborhoods, change schools, sell a car. What can you change to have more money available to you?
• Make it rain while you can: there are a lot of jobs in medicine that are temporary and pay well. These jobs might be a tool to help you create a more secure financial foundation. Review this Member Only article for more about Moonlighting and Side Hustles options.

The general saying for new small businesses is to plan for minimal to no profit for at least three years. This has not necessarily been the case for DPC startups, but in terms of managing money, if you chose to leave an employed position with a secure income and open your own practice, you need to plan for a dramatically different financial future. Stop spending; start saving now!

As a DPC physician, you have already shown the patient that transparent, fair pricing is possible within your walls; however, doing so outside your clinic can prove challenging. When referring a patient to another physician, here are the considerations and options:

DIRECT-PAY OPTIONS: Increasingly, specialists and other types of medical professionals are offering an upfront, direct-pay option for patients who wish to avoid the hassles of insurance. However, the number of specialty direct-pay options will be heavily dependent on your community and region. It is largely up to you (and your local DPC colleagues!) to forge relationships with specialists to create your cash-pay referral network. Share resources and direct pay specialists with your local DPC community. Consider a shared online folder with pricing lists for specialists who have shown interest in giving your patients direct service.

PATIENTS WITH INSURANCE: If a patient has an insurance plan with an “open” network* (most PPOs and Medicare), you can refer to a physician in their network as usual. The billing and patient costs may not be transparent. Advise the patient of this and encourage them to seek out cost estimates prior to service where possible. Small independent practices and facilities will generally have lower costs to insured patients compared to hospitals or large health systems. Also, it is worth noting that patients using insurance may end up with more out-of-pocket costs than they would have if using direct-pay options!

* If a patient has an HMO, these plans often require an in-network PCP, who is often assigned to the patient, to be the gatekeeper for all other care/coverage. This requirement is less than ideal for the patient and you. (See DPC and Insurance for more details)

Networking to find local direct-pay resources

There are a few ways to help you find existing direct-pay (also called cash-pay or self-pay) specialty and ancillary resources in your area.

• Local DPC physicians: Many have compiled a group of resources and are happy to share. Repay the favor by sharing future resources.
• Regional DPC groups: There are regional DPC clubs or organizations in some areas of the country that share resources, including direct-pay options. (Disclaimer: These have no official affiliation with DPC Alliance.)
• Charitable medical clinics/organizations: Some charitable clinics geared towards uninsured patients will have a list of providers in a community who have “cash” or self-pay rates. Reaching out to their doctors or practice managers may be helpful.
• City or county medical society. If you have an active local medical society, you should reach out to them to discuss any existing options. If none exists, you can use the organization to network with specialists who may be willing to see direct-pay referrals.
• Local physician-only social media groups: post on these groups describing the DPC model and what you are looking for in an independent specialist practice.
• Set up your own local social media group for independent physicians: Many physicians are too busy to attend networking events. Consider setting up a local DPC or independent physician social media group to get to know one another and encourage professional connection. You can use this to educate specialists in direct care and provide resources for them which many are unaware of.
• Hold your direct pay specialists to high standards of care: When you send a patient to a specialist, you have given that patient your recommendation. Cash pricing alone does not dictate the level of care. Do not settle. If you/your patient are dissatisfied with the care that was provided, it reflects poorly on your DPC reputation. Call and ask to discuss what happened. If the specialist is defensive/angry/uncommunicative/unwilling to be reasonable, move on. Find another practice who will work with you directly on your patients’ needs. DPC physicians have high expectations of specialists:
  • Direct communication between physicians
  • Timely appointments for patients
  • Follow up information from a physician after the visit
  • Price transparency and working towards bundled pricing
  • A positive patient experience

Direct Specialty Care

In 2021 Direct Specialty Care Alliance was founded, in response to the increasing interest of medical specialists in the Direct Care Model. DSC Alliance is physician founded, physician led, physicians helping physicians to offer direct care services.

As more specialists transition to Direct Care practices and transparent, cash, pricing, you can often find a specialist with the same values and a similar model to your DPC Practice. A directory of DSC Practices can be found on their website, www.dscalliance.org.

Social media can seem overwhelming to some physicians. There are many layers to social media both as a marketing tool and as a tool to further your brand identity. In terms of ‘starting up’, the following list will pay dividends for your practice future:

1. Once you’ve chosen a name, try to claim your handle on major social media forums. If your clinic name is “Rockstar DPC” it is ideal to own “www.rockstardpc.com”, as well as the Facebook, Twitter, and Instagram handles for “rockstardpc”. Consistent brand identity across forums improves people’s ability to find you on social media.
2. Claim and manage your online identity. Ratings matter. Search your name online and claim as many identities as you can. Places to start include healthgrades.com, vitals.com, your professional Google identity (aka Bob Smith, MD), and any of the top sites that come up when you search for yourself online.
3. Respond to online feedback and ask patients and colleagues who know you for reviews. This helps you build an online reputation. When a patient states, “Oh my gosh Dr. Bob, thank you for this!” ask that patient to go online and share their experience.
4. SEO stands for “search engine optimization”. As you begin working on your website, generate as much authentic content as you can. Work with a company on your website, or use resources such as Wix, Squarespace, Weebly, Fatcow, WordPress, or GoDaddy. The sooner you purchase your URL and begin to create content and get reviews, the stronger your SEO becomes. Also, make sure your website contains phrases that are commonly searched for. So, instead of saying Primary Care Physician, say Family Doctor. This will enhance your SEO in the early phases and help people find you.

For more detailed information on finding and managing social media handles see the article Securing My Practice Name on Social Media.

Driving web traffic to your DPC website is a vital resource for growing your membership no matter where you are in your DPC practice journey. This is where Search Engine Optimization (SEO) comes into play. 

SEO may seem like an arcane art, but as long as you have basic control of your practice website you can get the fundamentals of SEO working to your benefit. 

Benefits of SEO 

• Increase website traffic
• Increase member interest inquiries
• Convert general interest into member signups
• Naturally populate into the Google Business results 
• Increased visibility of positive patient reviews

1. Start with Your Practice Site and Site Content

There is no way around it, but to get started with SEO you need to figure out your web presence. What type of patients do you want to attract? What are the key aspects of how you practice in your DPC practice? Use your vision of DPC practice to set tailored keywords[LINK] that define who you and your practice are. Using the right keyword is the most important part of optimizing your SEO. More keyword tips can be found below.

Some general SEO tips for every website:

• Build your keywords into page content AND headers. 
• Include Page Descriptions for your site.
• Make a dedicated Contact Page that very explicitly provides
  • Name
  • Address
  • Phone Number
  • Public Email
• Put contact information on the website footer
• Make a dedicated Reviews/Testimonials page on your site - Google strongly weighs reviews directly written or posted on the practice site (“First Party Reviews”) and reviews left on sites like Google, Facebook, WebMD, etc. (“Third-Party Reviews”). 

2. Claim Your Google Maps Business Profile

The reality of our current ecosystem is that the first place many potential practice members will encounter your DPC practice is on Google. It is critically important that every DPC practice has claimed their Google Business Profile for Google Maps and Google Search results. 

This will give you more leverage to address incorrect or malicious Google reviews. 

Use this Google page to start the process of claiming your practice’s Google Business Profile account. You will need to go through the process to verify that you do, in fact, own the business. 

3. Research–and Use–Localized Keywords that Patients in Your Community Are Using

There are a host of free resources available for anyone that is interested in learning what customers in their community are using to search for primary care services in their area. 

• Once you have claimed your DPC practice’s Google Business profile you can use built-in tools like the Google Keyword Planner.
• To get a broader sense of keywords and search terms check out Google Trends.
• An alternative to Google–and independent of your Google Business Profile–is UberSuggest.

Shave biopsies are a great way to add value to your DPC practice. With an autoclave, you can make sterile shave biopsy kits for pennies.

Numerous resources exist (videos on YouTube, Pfenninger and Fowler’s Procedures in Primary Care textbook, etc) to easily learn this skill. Shave biopsy allows the physician to excise a skin lesion by removing a lesion without compromising the bottom of the dermis. They heal well with minimal scarring.

Flexible biopsy blades can be pricey, but flexible razors are very affordable and can easily be autoclaved with a set of Adsen forceps and a couple 4x4 gauze sponges. Bleeding is easily controlled with pressure, Monsel’s (ferrous subsulfate), and silver nitrate sticks, WoundSeal, or electrocautery.

https://youtu.be/9GoZPukjqrg

* This video is provided solely as an educational reference for DPC Alliance members.

First and foremost, create a financial plan to help guide you. You might want to talk to a local DPC mentor about their start-up costs and expenses to get a better idea of these numbers in your area. Remember that the lower your overhead and start-up expenses, the less you have to charge and vice versa.

• Calculate total start-up (one-time) costs = $ _____________
• Calculate ongoing (operating) expenses = $______________/year
• Determine desired self-pay (take-home) pay = $ _____________/year
• Determine what portion (if any) of your patient panel will be offered charity care
• Determine per-member-per-month need

Once you have these numbers in mind you should consider the type of population you want to take care of in your practice.For example, if you prefer to have younger patients or small families with children, you might consider instituting an aged-based membership. This gives a lower cost to younger adults and families with children under 18, who generally feel that they are healthy and only need care on occasion.
An example would be the following:

• Children up to age 18: $40 without adult membership, $20 with adult membership
• Adults to age 44: $60 per month
• Adults 45-64: $80 per month
• Adults 65 and older: $100 per month

Conversely, if you prefer to have older patients in your practice or perhaps you do not see children, you may want to institute a single cost per member, which may be higher than what a younger person would want to pay but lower for the older patients.

• For example, if your per-member-per-month need is $80 per member, charge each member a flat $80 per month.

Some prefer to set one cost for children and one cost for adults to simplify things. For example:

• Children: $40 per month
• Adults: $80 per month

If you are a pediatrician, you may want to consider a higher cost for newborns and infants when you know they will need more well care and lower the cost as they get older. For example:

• For children less than 2 years old – $100/month
• For children 2 to 5 years old- $75/month
• For children 6 to 18 years old – $50/month

Some doctors will set a “family rate”. While this can be a good way to gain members and young families, proceed with caution as some very large families may be very time intensive.

Obviously, there is no one right answer with regards to how to charge and every practice is a bit different. Consider your location and population as well. You might be able to charge more if you are in an affluent neighborhood or prefer to attract this population. You might consider charging less if your town's per capita earnings are low or your practice is in a lower-income part of town.

Remember, this is YOUR practice. You can choose to set pricing however you see fit.

One of the cornerstones of DPC is unprecedented physician access. The time DPC doctors have to devote to their patients and the access the patients have is what makes it what it is.

However, like anything good, too much of it can probably be bad.

One of the most frequently asked questions by doctors looking into transitioning their practice to DPC is some version of “But how can you be available to your patients by phone, e-mail, and text, and for urgent in-person needs, virtually 24/7 and still have a life?”

The answer is “It’s not as bad as it sounds.” It really isn’t. It helps that DPC docs have a limited patient panel size. That being said, every DPC doctor does have the occasional over-user. More on that later.

When it comes to setting boundaries with patients, generally we’re referring to what kinds of things patients can contact you for, when, how often, etc.,as well as how often they schedule appointments, how often they interact with your staff, etc. When deciding where to draw the line for these kinds of boundaries, most DPC docs will tell you that where you are in establishing your DPC practice will help define how strictly you set such boundaries.

Most DPC docs start out with fairly lax, --even very lax-- boundaries. We give our patients something amazing that they tell their friends about. There is tremendous value in a non-sustainable willingness to cheerfully answer a call about a lisinopril refill at 11:30 pm on a weeknight, or a text asking how many carbs are in a half cup of peanut butter on a Sunday afternoon. I know, I know, this sounds painful. And it is. But this pain is only temporary, for 3 reasons:

1. When patients use you in this way, it’s what Dr. Jeff Davenport has called the “New toy at Christmas phenomenon”. The toy gets played with a LOT for a short time, and before long is collecting dust somewhere. DPC services are often used like that. When the patients know you’re available, the novelty wears off, and you’re there if they need them, and the usage/text frequency drops off dramatically. 
2. Often patients who are new to you come from inside the system, where they have had poor continuity, polypharmacy and basically, medical neglect. Once these patients are “tucked in” and their issues sorted out, the usage frequency drops off.
3. As your patient panel fills up and you get to the point where your time is more limited, you can begin setting more strict boundaries with your patients. By this time, they have recognized the huge value of their membership, and they’ll back off with communications/usage that are unnecessary--if you ask them to.

OVER-USERS

So what happens when you have a full panel and 99% of your patients fall into the above-described categories, and recognize that you have 500 other patients and a life and therefore leave you alone for minutiae, but 1% of them drive you nuts? This is where we recommend more-strict boundary-setting. If you don’t set some boundaries, you’ll begin to resent the patient and the quality of care and the physician-patient relationship will be damaged. This is usually as simple as kindly asking them to call the office tomorrow and asking a staff member for assistance. Some docs will employ “therapeutic neglect” with over-users and won’t reply to frivolous messages quickly. There are numerous ways to kindly work with these patients to decrease over-use. In the rare circumstance where your boundary-setting offends a patient and they leave your practice, it’s probably for the best; they may not have been a good fit. And such patients are usually <1% of your panel, yet represent >95% of your text/e-mail interactions, so their leaving frees up a lot of time to use for other patients.

OVER-SETTING BOUNDARIES

Just as patients can over-use your services, doctors can over-set boundaries. Some DPC docs have lamented the lack of patient sign-ups and their having to moonlight to make ends meet due to the slow growth of their DPC practice. When auditing their business model, successful DPC docs have found that these physicians often have overly-strict boundaries. Perhaps the doctor doesn’t allow after-hours contact by phone, text or e-mail. Or perhaps the doctor doesn’t text with patients at all. This has the overall effect of lowering patients’ perceived value in the DPC membership. In essence, you have to give them something for their money, or they’ll take their money elsewhere.

Ultimately, every DPC doctor will find themself frequently moving around their boundaries as their circumstances evolve, to generate the perfect mixture of access/quality and work/life balance.

After naming your practice and purchasing the “.com” domain, it’s time to venture into the wild, wild west of social media. Don’t wait to find out if someone already has that Twitter handle you want!

There are several online resources which can guide you in your selection of social media “handles”:

• Namecheckr.com
• Shopify Business Name Generator
• NameMesh.com
• Naminum.com

For more information, check out Marketing Your DPC Practice: Target Audience

Welcome to the world of direct primary care. If you’re reading this, you’re likely in the position of owning your practice (or working with a DPC doc who owns the practice). This means: you’ve now got more control over your schedule than you’re likely ready to deal with.

Things to decide:

• How long will your initial visits be? Typically want these to be pretty extended. Often you will spend time talking about the logistics of the practice and how you accomplish taking care of pts as well as the typical new pt medical things.
• How long will your follow-up visits be?
• How long will you schedule for procedures? Obviously, this may differ for different procedures. Don’t forget to consider when you need assistance and/or chaperones
• Will you take walk-ins?
• Do you need a buffer added to your visits to complete notes? Put in orders?
• How many days a week do you plan to see patients? Will this change as you grow?
• How much can be triaged to your staff? How much do you want to triage directly?
• What expectations do you want to set for text, email, phone, and/or in-person visits?

Once you decide your schedule and preferences, various software providers can help automate your scheduling while others don’t allow for outsourcing your scheduling:

• AtlasMD (via their Mac App)
• MDHQ
• Elation
• Calendly, Google Calendar

Keeping your Schedule Open

Some DPC doctors are emphatic that schedule management should be carefully triaged and managed by either the physician or a highly trained staff member (to keep the schedule open and address things without an in-person visit). Others open their schedule to direct scheduling so that no clinic bandwidth has to go into scheduling. Each has its pros and cons; decide what flow you think fits best.

Additionally, there are many opportunities to train up your nursing staff to provide basic care visits (any visit that can be directed by an explicit algorithm -- cerumen washout, uncomplicated UTIs, strep visits w the Centor Score, Ottawa ankle rules, etc., etc.).

Price transparency and direct-pay websites

There are several online resources to help search for existing direct-pay specialists and other medical professionals. None of these websites have a great density of providers in every community nationwide, but worth checking out to see if any good resources are listed in your area.

There are a few types of websites in this realm.

Directory of “direct-pay” practices without pricing information.

• https://jointhewedge.com/find-a-practice/
• https://aaps.wufoo.com/reports/m5p6z0/

Price transparency websites. Reporting of information (i.e. average payment/reimbursement) but not technically a price or offer.

• https://clearhealthcosts.com/
• https://www.healthcarebluebook.com/
• https://openpaymentsdata.cms.gov/ (Medicare payments)
• https://www.fairhealthconsumer.org/

Online booking platforms with real pricing & sometimes scheduling.

• https://www.medmo.com/
• https://www.radiologyassist.com/
• https://www.colonoscopyassist.com/
• https://www.mdsave.com/
• https://www.medibid.com/
• https://fmma.org/shophealth/
• https://pricinghealthcare.com/
• https://sesamecare.com/
• https://uber-docs.com/
• https://medoplex.com/

START UP LETTER/SIMPLE FORMS

First Office Transition Letter

Second Office Transition Letter

Credit Card/ACH Authorization Form

Record Release Form

First Missed Payment Notice

Second Missed Payment Notice

Letter to Confirm Membership Cancellation

Communication Guidelines for Patients - Micropractice

Communication Guidelines for Patients - Office with Staff

ADVANCED PRACTICE FORMS

Staff On-Boarding Checklist

Staff Off-Boarding Checklist

Employee Termination Letter

Photo Release Form

Procedure Consent Form

SAMPLE AGREEMENT FORMS

Patient Agreement

Medicare Opt Out Patient Agreement

Staff Contract

Provider Contract

Compensation Amendment

Employer Agreement

Non-disclosure/Non-Solicitation Agreement

Membership Termination Letter

Some physicians elect to transition their current private FFS practice to a hybrid DPC practice, meaning that part of their practice is made up of pure DPC patients and the other part is still insurance-based fee-for-service. Some physicians elect to continue Medicare contracts only in order to both keep Medicare patients as well as keeping the ability to moonlight in more traditional settings. Other physicians prefer to keep all or part of their commercial insurance contracts. Still, others use hybrid as a stepping stone to eventually become a pure DPC practice over the course of months to years.

Some of the reasons people give for wanting or needing to do a hybrid practice:

• Some insurance contracts can take 90 days or more to cancel. Ignoring this requirement leaves a physician liable to a breach of contract allegation.
• The physician may be the sole breadwinner of their family and they fear that losing most of their patients all at once will put them into a difficult financial position
• The need to continue moonlighting opportunities which are more limited when you opt-out of Medicare.
• Concern for abandoning patients or losing patients they have seen for years
• Wanting to continue seeing a large portion of patients over 65 who may not be able to afford services not covered by Medicare

The potential benefits of running a hybrid practice include:

• The ability to drop insurance contracts at a slower pace allowing the practice to continue a more steady revenue stream during the transition
• The ability to support family and lifestyle while transitioning, including having the flexibility to moonlight for extra income

The potential disadvantages of running a hybrid practice include:

• Potentially competing against yourself. It may be difficult to recruit patients to DPC when you are continuing to support their using insurance to pay for your care.
• The need to differentiate care for DPC patients vs. Insured patients (It can create a perverse incentive. You would want to enroll DPC patients but are financially incentivized to pack your schedule with insured FFS patients.)
• The need to continue administrative tasks and inability to lower overhead due to the need to continue maintaining the staff and software to deal with insurers and meet data collection requirements.

If you’d like to read a little more about hybrid DPC practice, this is a great article by Dr. Lee Gross.

Most patients will be intrigued by what you are doing, especially if you get really good at getting your point across in a few sentences. Some get it right away and are ready to take the plunge with you. Others take a little more education but eventually come around. Some don’t understand right now, but once you are gone and they get lost in the system, they realize you were right and come find you.

The most difficult thing to deal with are those patients that get angry. These patients just don’t understand and some feel you must be leaving them because you are looking to line your own pockets.

If you must deal with someone who is angry face to face, stay calm, and let them know that this was a decision you did not take lightly. Let them know you are very sorry they are angry but that you are doing this for both the improvement of patient care, as well as for your own sanity. Don’t try to reason with them if they continue to be angry. Just let them walk away.

If you are dealing with someone who is angry and has verbally abused your staff, call them directly and try to allow them to voice their concerns. Again, be calm but firm in how you deal with them.

Lastly, combat anger with education. Give your patients plenty of opportunities to learn about your new model. Send out letters, hold town hall meetings and allow for plenty of time for questions and answers, make Facebook posts, talk to all your patients at each visit leading up to your opening date. Think about scheduling fewer patients if possible and having a little more time with each one to talk about your DPC future.

Here are some upsides and advantages to working with employers:

1) ACQUIRE NEW PATIENTS MORE QUICKLY. If you can land several small to medium-sized employers, you can build a robust panel of patients quickly. You must have the capacity to add new patients and also to manage the new encounters as employees are added—are you ready? As your relationship with employers strengthens, other employers in the area will want a piece of the DPC action which can lead to further growth of your business.

2) STABILIZE REVENUE AND FEWER COLLECTIONS. Adding new patients with guaranteed payment directly from an employer improves the finances and offers a much easier way to deal with collections. Getting one check or ACH draft for 100 employees all at one time is much cleaner and faster than individual billing. No need to chase down individuals with old accounts or failed payments.

3) LOWER UTILIZATION. Historically, a majority of employees use medical services much less than individual payers. This has been observed across multiple types of employers. When an employer pays for the plan, many employees utilize the service less -- even with our persistent prodding via email and text. Of course, there will still be lots of complex patients from employers but this is usually offset by many who will rarely come.

4) GETTING EMPLOYEES HOOKED ON DPC. DPC is providing a high level of care in comparison to the low bar set by traditional FFS medicine. Once DPC is tried, there is no going back. As employees get "hooked" on it, you shift the whole care paradigm—lower costs, more access, healthier employees, and fewer insurance claims. Even without the employers, eventually, the patients (employees) will still want DPC. Win!

Also when you take good care of the employees often you will get members of their family to sign up and pay you directly. Also word of mouth marketing. They will tell their neighbors and friends.

Learn about the Cons of Working with Employers.

“Pre-enrolling” entails signing up patients (members) prior to your official opening date, so that, when the time comes to open your practice, you can bill patients from your first day of practice. This allows you to have a revenue stream from the very beginning. While this seems enticing, there are a few things to consider when doing this:

EXISTING OBLIGATIONS: If you are in an existing practice, you need to clarify any employment obligations and current insurance contracts before creating a pre-enrollment process.

FIRM(ISH) LOCATION & OPENING DAY: In order to pre-enroll, you should have a fairly solid clinic location secured and an opening date, hopefully, 3-6 months (or longer) in advance.

PRACTICE DETAILS, FORMS, & POLICIES: Have you created a patient contract[UPDATE LINK]? Are you building a website with embedded enrollment forms? Does your EMR potentially have a link you can embed into your website? Do you have business cards or flyers? Having these all in place prior to starting a pre-enrolling process is advisable.

PATIENTS COMPLETING FORMS:

• Online enrollment is likely the easiest choice here. This generally involves using your chosen membership management or billing program.  which will allow you to embed an enrollment form on your website.
• You can have patients manually (in-person) complete required forms and then enter information into your systems later. This can be more leg work, but some doctors prefer this method to make sure patients understand the model and are a good fit.

ROLLING START DATES? If you are successful in pre-enrolling hundreds of DPC patients, you may consider using a staggered start date for their membership. If you are pre-enrolling your current patients that is the best of all worlds. You already know them and won't have to have a “new patient” visit to get to know them.

A saying about retail enterprises is to consider “location, location, location.” And the location is that important to your success. Where you decide to open your clinic in terms of city/town is largely up to you. There is no one recipe or one right answer. It is logical to assume that if you move to a community completely new to you and open a practice, your growth will be more challenging. Physicians who have done this have had varied experiences. It also seems logical that if you open a practice in your hometown, growth will come more naturally. This, also, is not always the case.

Lease or Buy (or Free!): For the most part, the best recommendation for an entrepreneurial start-up is to stay as financially lean as possible. What does this mean? Spend as little money as possible and commit to as few ongoing expenses as possible. If you can’t afford it now and you don’t absolutely need it, don’t buy it, lease it or sign a contract for it. The Lean Startup is a great resource on this topic.

1. Free: if you can find a room in another health-related space and trade care for office space, this is the leanest start-up option possible.
2. Rent a space: find another physician or other business that will sublet space or a room in their office to you
3. Buy or rent a Facility: find a building to buy or rent

Direct Primary Care (DPC) offers a seemingly perfect solution for physicians and patients; however, it is not perfect. As such, DPC comes with some unique challenges.

• Marketing and Community Outreach: Developing a marketing strategy to effectively communicate the benefits of DPC to potential patients is essential. This might include online presence, community events, or partnerships with local businesses.
• Patient Acquisition: Attracting and retaining patients can be challenging, especially in a new market. Building a patient base and getting the word out about your practice is crucial.
• Business Ownership: Starting any business has its challenges, but when you are starting and building a model of care which directly threatens the current model, you may be faced with contrarians and opposers who may propagate their assumptions about what DPC is. This can make growth difficult initially. That is until you prove them wrong - which you will do.
• Financial risk: You will need to prepare for and accept the risk of receiving less income initially. You may need to supplement your income in other venues such as Urgent Care Clinics, Emergency Departments, etc as your practice grows. (Review the Member Only article Moonlighting and Side Hustles for more information)
• DIY Medicine: It can be very nerve-wracking as you may have to find “hacks” to help save patients money or even venture into areas of medicine which you hadn’t fully considered such as performing venipuncture, scheduling patients, answering your phone calls, and/or re-learning procedures you may not have done in a while.
• Patient Relationship Management: Building strong, trusting relationships with patients in a membership-based model requires a shift in how you interact with them compared to traditional fee-for-service models. Some patients may overestimate their relationship with you or grow to feel entitled to the care and attention they receive from you. Setting clear boundaries early on in the patient-physician relationship is highly recommended. Specific patient populations may pose certain challenges. “Low utilizers” may not find value in a monthly membership for a service they don’t regularly use. “High utilizers” may have a false sense of entitlement of what they think you should be providing to them. Other patients may overestimate their relationship with you assuming that, in addition to being their physician, you have a more personal relationship that can easily be abused.
• Recruitment and Staffing: Typically physicians would not have any experience with hiring/firing or creating the healthcare team that they work with daily as this was formerly done by the employer. However, in DPC, you’ll have full responsibility to create the team that will embody your vision of practicing good medicine. This can be both exciting and challenging.

There are many labs and tests that can be done without sending samples to an outside lab or pathology group:

• Urine dipstick
• Rapid strep, mono, influenza A/B, covid
• Urine pregnancy testing
• POC INR, Hgb A1c
• Fingerstick glucose
• Stool FIT testing or fecal occult blood
• Urine drug screening cups

If you are doing any testing on any body fluid or tissue, you will need to have a Clinical Laboratory Improvement Amendments (CLIA) Waiver. Some states have specific applications and requirements for CLIA certification, so speak to a DPC doctor in your state for guidance. Once you have applied for, paid for, and received your CLIA waiver, there are a whole host of tests you can offer within your practice. These tests can be easily obtained through any major medical supply wholesaler (and will often note that the test is “CLIA Waived” or not). In some states, in-office testing is allowed without major regulatory oversight with the assumption that you are doing it correctly, of course. Some states require “competence certification” so, once again, speak with a DPC doctor in your state. The onus is on you, and your license, to ensure that anyone performing this in-house testing is properly trained on the full instructions for each test.

For a high-level overview of arranging labs outside of your practice, see this article on Arranging Client Billing Labs.

In direct primary care, there is no one and nothing limiting the scope of your practice or the procedures you choose to provide other than your own training and comfort level (and maybe your malpractice insurance). One of the newer technologies that can be easily provided in the DPC setting (and at a profound savings) that has documented efficacy in the treatment of osteoarthritis is platelet rich plasma injections.

PRP is part of a promising new realm of regenerative medicine that has been referred to as orthobiologics. The physiologic efficacy of PRP therapy is based on the fact that the autologous use of platelet growth factors supports three phases of wound healing and repair (inflammation, proliferation, and remodeling). The following full text article gives a great synopsis of the understanding of the physiologic benefits. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589810/

PRP has been adopted widely for use by orthopedists and sports medicine clinics and because it is not covered by insurance has been a lucrative cash based procedure for fee for service physicians with many clinics charging $750-$1,000 for PRP injections. Direct primary care physicians are in a unique position to offer this promising therapy to patients at significantly less cost to the patient while still being a profitable procedure to incorporate into their scope of practice.

The most well supported use of PRP in the literature is for treatment of knee osteoarthritis. In this application it has even been shown superior to intra-articular corticosteroids. However, the use of PRP has expanded to a variety of other burgeoning applications that can be utilized in the primary care setting including treatment of other joints, tendinopathies, wound healing, and cosmetic procedures. Platelet rich fibrin (PRF) is a related biologic preparation that shows promise in wound healing and hair regrowth applications.

1. Overview of PRP for skin rejuvenation - ie: Vampire facials and intradermal injections https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182581/
2. Overview of PRF for wound healing - https://www.sciencedirect.com/science/article/abs/pii/S0965206X21000656?via%3Dihub

One of the difficulties with the universal application and acceptance of PRP is the lack of a consensus in preparation methods. This has contributed to inconsistencies in PRP therapies, with enormous differences in PRP formulation, specimen quality, and, thus, clinical outcomes. Additionally, different formulations of PRP, such as leukocyte rich or poor preparations, are better for different applications.

The variability of specimen preparation methods highlights the need for working with a supplier that allows you to obtain high quality product on a consistent basis. Several options are on the market with the following links available to companies that other DPC doctors have utilized.

Ensodoctors - A veteran owned company based out of Manhattan, KS with educational materials online and in person training available to utilize their collection kits for PRP and PRF. It deserves to be said that EnsoDoctors has been a company that not only provides quality collection kits and education but wholeheartedly supports the direct primary care movement and offers discounts to DPCA members.

1. https://ensodoctors.com/
   
   They also offer free PRP to veterans through their “Shots for Soldiers” program.
   
   https://shotsforsoldiers.org/
   
2. Arthrex - Based out of Florida with large online compendium of educational materials with in person training available and nationwide network of product representatives. https://www.arthrex.com/representation-finder

Point of Care Ultrasound, or POCUS, is a quick ultrasound exam performed at the bedside in order to answer specific clinical questions in a timely manner. There are now many handheld devices that have made ultrasound easier and more accessible to clinicians in all types of settings, including ER, ICU, outpatient clinics and even home visits. Furthermore, bedside ultrasound can also be used to assist in procedures such as musculoskeletal injections, endometrial biopsies, IUD placement, cyst or abscess drainage, among others. 

Most DPC physicians use their handheld ultrasound probe similarly to the way a physician uses their stethoscope, answering yes or no questions, such as: Does the patient have hydronephrosis? Does the patient have gallstones or a Murphy’s sign? Does the patient have lung consolidation or pleural effusion? Does the patient’s knee have an effusion? These yes or no questions may then need further work up or a procedure, but POCUS will lead the clinician to the correct diagnosis by ruling out or ruling in disease. 

There are many different handheld models available. Here is a great overview of the different types including costs and benefits: https://www.aafp.org/fpm/2020/1100/hi-res/fpm20201100p33-ut4.gif

So how do you get started?? 

We definitely recommend that you start by attending one of the many ultrasound courses available. A few of the best ones are listed below. 

POCUS Courses: 

We will try to keep an up-to-date list of ultrasound courses that are available to DPC doctors. If you have one you would like to add to the list, please let us know! 

• The American Institute of Ultrasound in Medicine. Portland, Oregon
• Portland Point of Care Ultrasound Course. Portland, Maine
• Point of Care Ultrasound for General and Hospital Medicine. Greenville, SC
• Introduction to Primary Care Ultrasound. University of South Carolina, Columbia, SC
• 10th Point of Care Ultrasound Workshop. University of Texas Health San Antonio, TX
• Global Ultrasound Institute (GUSI)

Here is a review of point-of-care ultrasound devices for more in-depth information. 

(This list was updated as of 5/11/2022)

An essential part of starting your own small business is deciding on a name. Your business name is a fundamental part of your brand and identity, and a good one can help your practice grow. Many DPC practices have names consistent with the values of returning autonomy and integrity to the practice of medicine. Below are broad categories of practice names, with examples of each:

• Inspirational/aspirational: Paradigm Family Health, One Focus Medical, Freedom Family Health, AtlasMD, and Command Family Medicine.
• Ancestral/name that has personal meaning: NeuCare Family Medicine, Oodle Family Medicine, Antioch Med.
• Location/hometown nomenclature: Examples: Glacier Direct Care, Hometown Direct Care, DirectMD Austin, Kansas City Direct Primary Care, Holton Direct Care.

You can also simply use your name and degree, especially if your long-term plan is a solo practice.

You should strive for a name that is:

• Easy to spell and say. Keep it simple to avoid confusion, misunderstanding, and misspelling. Some names look great on paper but sound awkward or confusing when said aloud.
• One that you are happy with and that resonates with your patients.
• Catchy and memorable. Ask friends and family for feedback.
• Not taken: search the internet, as well as Secretary of State and US Trademark search to avoid finding that “perfect name” that someone else already owns!
• Available on social media. Securing the “.com” domain for your business enhances your professionalism, as does having a consistent social media “handle” across Facebook, Twitter, Instagram, and Pinterest. It’s best to get these right from the start!

Your practice name will be incorporated into all of your marketing material, signage, business cards, flyers, posters, social media accounts, and more. This is your brand, and a solid name helps you shape the unique look and feel of your practice.

For related information, check out, Securing Your Name on Social Media.