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!

There are several EMRs to choose from now, many geared specifically for DPC practices.

Below are some general questions to get you started in choosing the EMR that's the best fit for you.

Be sure to ask for a demo and also references of current users and recent users who terminated.

EMR SUPPORT

• Is support response available within 24 hours?
• Is the company open to suggestions to improve the EMR?
• Is customization allowed?
• Are auto-updates available, and without fees?
• Is it HIPAA-compliant?
• What happens when you want to switch to a different EMR, and costs?

EMR PLATFORM

• Is it compatible on iOS/ Android / Windows / Chrome/ other platforms?
• Is it viewable and fully functional on mobile devices (phones/ tablets)?
• Is it cloud-based?<//li>
• Is it paperless capable? i.e. forms can be filled out online
• Can data be easily uploaded to a local storage source (in-house server / hard-drive)?

COSTS

• What is the set-up fee?
• Is there a trial period?
• Is there a contract term?
• What is the cost per user or per patient panel? If cost is based on patient panel size, are inactive patients' charts counted in the patient panel?
• Is there a cost to maintain inactive patients' chart (for the required 7 years)?
• Which features are built-in and included, and which features integrated with separate vendors and are added costs?

INTEGRATIONS

EMRs may have extra costs for these features here, or may integrate with other companies to provide these services:

PHONE NUMER

• Is a separate business phone number provided?
• Is there an added cost for the phone number?

TEXT/MESSAGING/PORTAL

• Are texts/emails/calls imported or uploaded to patients' charts?
• Is there a patient portal for secure messaging?

WEBSITE

• Does it integrate with your practice website for patient self-scheduling?

FAXING

• Can you send and receive faxes?
• Can you edit faxes within the EMR?
• Is there an added cost or a limit to how many pages can be faxed?

LAB INTEGRATIONS

• Are lab interfaces uni-directional or bi-directional?
• Can your order labs for self-pay as well as insurance?

MARKETING

• Does the EMR support mass e-mail or integrate with a mass email service (ie Mailchimp or Active Campaign)?

Which other vendors are integrated?

PHYSICIAN FACTORS:

• Does the layout of the patient chart fit your style (i.e. having everything on one page vs. having only the active screen on the page)?
• Is it customizable?
• How easy is it to search? Is search based on patient criteria or within patient notes?
• Is there a built-in telemedicine platform?
• Can you message/email/text patients from within the EMR?
• Can you schedule a future message/email/text to patient?
• Can you track patient results & referrals?

CHARTING

• Are there templates, macros, short-cuts, right-click menus or hot keys?
• Is free-text allowed?
• Is there a lot of clicking or typing required?
• Is it better for large/detailed notes or small/simple notes?
• Can you import images? Can you draw on them are you import?
• Can vitals and labs be graphed?
• Can you set patients' preferred pharmacies, specialists, facilities, etc?
• Does it support dictation?
• Can you unsign/amend notes?
• Can you delete documents?
• Can you easily reassign documents to other patients (ie if you accidentally assign it to the wrong patient how easy is it to more)?
• Are there custom workflows in notes (i.e. if ICD codes are required)?
• Are pediatric growth charts integrated and appropriate?

PRESCRIBING

• Are medication databases updated regularly?
• Is e-prescribing available?
• Is e-prescribing available for controlled meds PDMP?
• Is there an added cost to e-prescribing?
• Can you add compounded medications?
• Are supplements fully integrated like prescriptions?
• Is there a medication interactions feature?
• What is the appearance of the medication list?
• If you're dispensing meds, is inventory management integrated?
• Are alternative and complimentary treatments in the database?

PATIENT FACTORS:

• Encouraging patients to use their patient portals allow patients to schedule appointments, ask for refills, and send secure messages.
• Is there a patient portal and is the patient portal user-friendly?
• Does the patient portal allow self-scheduling, refill requests, document retrieval & uploads, and secure messaging?
• Are patients able to sign forms online (ie patient agreement, surgical consent, etc)?
• Can patients upload documents and pictures?
• Can patients view appointment summaries?
• Can patients enter their own credit card number, pay bills, etc?
• Can appointment reminders be texted?

BUSINESS FACTORS: (practice management)

BILLING

• Does it include a billing software? If not what billing software does it integrate with?
• Does it include a membership subscription & billing manager?
• Can you assign different charges for different groups of patients?
• Can you adjust charges at the time of billing or when necessary?
• How easy is it to add a one-time charge (like labs/medications)?
• Can you create a superbill?
• Can you easily print a claim form for patient to submit to insurance?
• Can you easily print an invoice for patient to submit to employer?

INVENTORY

• Does it have built-in inventory management for medications and supplements?
• Is there an RX label generator for dispensing?

TEAM & TASK MANAGEMENT

• Can you assign tasks and reminders to different staff?
• Do tasks have to be linked to a patient, or is there a way to send non-linked generic office tasks?

POPULATION MANAGEMENT

• Can you extract population data?
• Is there automatic notifications of screenings or population needs?
• Can you upload any handouts you'd like?

Nothing solidifies a patient’s commitment to your services than saving them money, and imaging is one of the areas most ripe for cost savings. It’s also a lot of fun to realize that there are deals out there that you were likely never aware of when you were part of the “system”. Most patients assume that using insurance is the best way to obtain the best deal and save the most money. With the insurance based pricing structure, high deductibles, and coinsurance, in the vast majority of cases, nothing could be further from the truth.

The level of imaging utilization and run away pricing in the U.S. healthcare network wastes hundreds of billions of dollars per year (If the U.S. did less imaging, fewer numbers of the 25 most common procedures, and lowered prices and the number of procedures to levels in the Netherlands, it would translate into a savings of $137 billion.) (Source)

The average cost of a CT exam in the U.S. was $896 per scan as compared to $97 in Canada, $279 in the Netherlands, and $500 in Australia. Additionally, the average cost for an MRI in the U.S. was $1,145 compared with $350 in Australia and $461 in the Netherlands. (Source)

With such large profits at stake for the system, how in the world can we work effectively on our patients’ behalf to save them money and negotiate fair pricing? While the facilities available will vary regionally, a few fairly simple principles apply nationwide.

AVOID HOSPITAL BASED IMAGING! - Results show that average hospital prices range from 70 percent higher to 208 percent higher (nuclear medicine) than the average prices at free-standing imaging centers. (Source)

UTILIZE FREE-STANDING IMAGING CENTERS - The pricing at free-standing imaging centers will be significantly lower for patients whether they choose to pay cash or have the charges submitted to insurance. It is worth having a discussion with the centers near you to obtain a list of their cash prices. At times, they will offer additional discounts for client bill pricing in which the imaging center bills your clinic for the imaging, and you then collect fees from the patient. Whether the benefit to patients is great enough to warrant the additional financial risk and administrative burden to your clinic will vary from practice to practice.

ENCOURAGE USE OF CASH-ONLY IMAGING COMPANIES - Similar to the growth in the DPC arena, over the past decade, several of our radiology colleagues have discovered the freedom of refusing to deal with insurance. Cristin Dickerson, MD founded Green Imaging in 2011 and has grown the company to a nationwide presence. Similarly, RadiologyAssist was started as a way for the uninsured population to obtain imaging at discounted cash prices but is available to anyone who chooses to pay cash rather than file their insurance. Rather than building their own imaging centers, these companies purchase unused capacity at existing imaging centers at a discount and pass that savings along to the patient. The caveat with these cash-only companies is that patients must pre-pay for their services prior to scheduling, however they can utilize Care Credit or a layaway type plan in many cases if paying the entire cost is still a challenge even at the discounted rate. At Radiology Assist the price for plain films starts at $33 and MRI as low as $265. These networks are expanding rapidly but as of now, they are not available in the far northern states including the Dakotas, Nebraska, Wyoming, Montana, and Idaho. Ordering imaging through these companies is simple and can be done online or by uploading a referral form.

https://greenimaging.net/

https://radiologyassist.com/

Written by Kelsey Smith, MD

Any venture worth doing is worth doing with someone else. As you are building your business vision and laying out a plan for your start-up, ask yourself: who is your business team?

DOMESTIC PARTNER

When considering DPC, physicians with a domestic partner should involve their partner in the decision to switch. Working together to realize your dreams can bring you closer or apart, depending on how invested your partner is in your DPC dream. Whether you have a partner who can hold down the fort at home, provide income and health insurance, offer design/graphic device, help with keeping the books, do the billing, run your office or just enjoy dinners while you ramble on about all of your ideas and needs, a supportive partner is a critical component to business success.

LOCAL INDEPENDENT PHYSICIANS

Seek out like-minded entrepreneurial independent physicians of all specialties. Most are intrigued by the Direct Primary Care model and are eager to work with our cash-paying patients as less billing means less overhead. You may develop a local network of supportive specialists, not only with patient care but also with physician entrepreneurship, which can sustain you through difficult or lonely times.

LOCAL BUSINESS NETWORKING GROUPS

There are business networking groups that can be very helpful in introducing you and your business to your local business community. Be prepared to join as a member and go to meetings and events to network with other small business owners. Be aware that networking takes TIME and many conversations but eventually as you and your DPC model become well known and trusted, you will begin to get referrals.

• “BNI”- Business Networking International.
• Chamber of Commerce/Local Business Associations
• Faith community (if that applies to you) Consider offering to give presentations on medical topics (not DPC) to increase exposure in your community
• One Million Cups
• Meetup.com (look for entrepreneurial groups)
• Civic groups like Rotary International and Lions Clubs can all help you establish connections and useful business relationships. They may not bring in a substantial number of patients but they will help with your business acumen and word of mouth knowledge in your community.

Other members of your team worth considering include:

• Accountant
• Lawyer
• Business mentor. Use your business networking meetings to learn tips for running a business from other entrepreneurs.

LOCAL AND NATIONAL DPC PHYSICIANS

Call or email your local established DPC physicians. Most will be happy to hear from you and help you along the way. Some are less interested in being part of a wider DPC community - don’t take it personally! The national DPC community is full of physicians willing to help you get off the ground. Check out the DPC Alliance member directory, send an email, and ask for help. See How to Find Your DPC Mentor for suggestions.

Steps toward financial stability include:

1. Getting a firm hold on your personal/home finances. (See Financial Consideration)
2. Write a business plan with financial projections. A guide to help with your business plan is available from the Small Business Administration. You may also find some free in-person help through a Small Business Development Center at your local college or university. (See Writing a Business Plan).
3. Important elements for initial financial projections include:
   • Determine your pricing. Many variables go into this. (See Setting Membership Pricing).
   • Anticipate and budget for one-time expenses needed to open.
   • Plan for and budget your ongoing business expenses.
4. Choose your accounting software. Check out Xero.com and Quickbooks.intuit.com.
5. Find an accountant with small business expertise to help you transition from being an employee to a small business owner (which comes with the responsibility of properly tracking expenses, managing write-offs, utilizing the business to pay for business-related expenses, and tracking owner contributions and owner distributions -- among others).

We’ve all seen that patient. The one who has tried EVERYTHING for migraines and nothing works. They had too many side effects on triptans, topamax, verapamil, or propranolol. Acupuncture, massage, oxygen, and cryohelmets were not effective. You may know there are some injections that can be done, but perhaps your patient doesn’t have insurance and can’t afford to see a neurologist.

Prior to referring your patient out, you may be able to try some of these injections in the office.

First and foremost, it’s important to find out if there are any specific triggers for the patient’s headaches. Some people find that stress and tension seem to cause neck pain and trigger migraines. For these people, you can start by trying simple trigger point injections into the cervical paraspinal muscles once every few weeks until their headaches diminish. You can use 0.5-1 cc of 1% plain lidocaine in the points of maximal tenderness, but some like to use a little steroid, such as Kenalog, as well.

If you want to go even further you can do a simple occipital nerve block procedure which involves injecting lidocaine over the occipital nerve to block pain.

Here is a great video on how to do this procedure.

In combination with cervical trigger point injections, occipital nerve blocks work very well for migraines associated with cervical muscle spasms. Some patients respond well even if they don’t have associated neck tension, so it is worth trying if their migraines are intractable.

Three other nerve blocks may be helpful for more traditional migraines or frontal headaches. These are the supraorbital nerve block, supratrochlear nerve block, and sphenopalatine nerve block.

The supraorbital and supratrochlear blocks are generally done together. The supraorbital block is easiest and sometimes useful on its own. For this block, you inject about 1 to 1.5 cc of 1% lidocaine just over the supraorbital notch.

The following video is a great overview of these injections for migraines. This surgeon also does a trigeminal nerve block, which may also be useful but not as common.

On a side note, keep in mind you can do a simple supraorbital block for forehead lacerations.

Here is a video example of this. 

Lastly, you can try a sphenopalatine block. There are many ways to do this block.

The easiest (but also the most expensive) way to do this is to use a special catheter.

There are 3 devices: Sphenocath ($670.50 for a 10 pack), the Allevio ($625.00 for a 5 pack), and the TX360 used in the MiRx protocol ($650.00 for a 10 pack). The nice thing about these catheters is that you can access more precisely the correct spot over top of the ganglion every time. When setting your price, be sure to cover the cost of the catheter, lidocaine, and a small markup for credit card processing. Dr. Blackwell at Clarity Direct charges $90 per SPG block, which patients are happy to pay as they typically experience about 6 weeks of relief. Although not ideal, catheters may be reused up to 4 times before they stop working. Dr. Blackwell does not charge for blocks when a catheter is reused. Make sure to clean it well by soaking it in alcohol after use and clean it before keeping it in the original box for the next use.

Here is a video of Dr. Kissi Blackwell, a DPC Alliance member demonstrating. 

You can also use a very inexpensive angiocath on the tip of a syringe, but you can potentially miss the spot since they are not very long, but they are much less expensive than the special catheters and worth a try.

Here is a video showing an ER doctor doing this for acute migraines. He states in the video they last just a few days and he does them weekly or biweekly for patients, which possibly means that this technique is not quite as good at reaching the ganglion as those who have had blocks using the procedure-specific catheters typically report 6 weeks of relief or more.

If you would like to learn a little more, this is a really nice overview of the sphenopalatine block and the premise behind it linked here.

* All videos linked in this article are provided solely as an educational reference for DPC Alliance members.

The most common way for a DPC practice to arrange lab services is via a client billing (this phrase is key!) arrangement if it’s allowed in your state. Effectively, this is a “pass-through” arrangement where the lab company bills the practice (the “client”), rather than the individual patient. While not truly direct-pay or self-pay, it’s what most lab companies are comfortable doing to offer better pricing. The process for setting up a client bill is fairly straightforward but does require a few steps:

In some areas, the most time-efficient way to establish client billing with a lab may be through a GPO/GPP. There are many GPOs/GPPs that offer this service. The advantage is that it requires very little work on the part of the physician, but the trade-off is that you may not get the absolute best pricing available. One such example is the DPCA GPP program.

Finding a lab company willing to offer a client-bill arrangement

These options will be very dependent on your location but both small locally-owned lab companies and large national lab companies have worked with DPC practices around the country. The easiest option to get started here is to speak with a DPC doctor in your area to see which lab companies have been most friendly and affordable.

The nationwide lab companies with the largest menu of testing are Quest and LabCorp. These companies have local/regional representatives that you will work with. You can typically identify a representative through their websites or by speaking with a local DPC doctor. The regional variability (service & pricing) is significant so, once again, speak with a local DPC doctor.

Obtaining a contract for your desired labs and prices:

If you are starting from scratch (no existing DPC or standard client-bill pricing) with a lab company, you may need to start with a smaller list of labs. Even though you may need 100+ lab tests eventually, having fair pricing on your 10-20 most common labs is something to build on; you can add more later. Be aware though, if you select something with “reflex” and the additional labs are not on your list you will get a LARGE bill for the reflexed labs.
Once services and pricing are agreed to, the lab company typically arranges a monthly bill with your business.

Phlebotomy options

Decide if you are going to offer onsite phlebotomy. Many lab companies will provide some basic supplies (needles, tubes, etc.) and equipment (centrifuge, label printer, etc.) at no cost to you. If you do onsite phlebotomy, your options will be to arrange to pick-up from the lab courier or to mail the sample depending on the lab you are working with.

Most lab companies will have a “service center” that can do phlebotomy but may come with an additional “draw fee” that should be included in your client bill contract.

When your practice reaches the point that you need to start hiring, you want to make sure you fully understand the differences between 1099 independent contractors and W-2 employees. If you are hiring people to work for you full-time, then you will likely have to make them an employee. Also, if you control how many hours they work, give them benefits, and pay them a salary, that also makes them an employee. I encourage my practitioners to be independent contractors as that puts them in control of their income and taxes. As an employee, they cannot write off any expenses, but as a 1099 they can take advantage of deductions and reduce their taxable income. Doctors get killed in the high tax bracket as a W-2. That does make some people nervous though, so I do offer the option to be a W-2 but their pay will be a little less as I have to cover payroll taxes on top of their salary. I pay 60% of membership revenue for my independent contractors and 50% for employees.

Know that you can get in trouble with the IRS if they decide that your independent contractor is actually an employee. Say they work for you for 5 years, then the IRS makes that determination, you will have to go back and pay 5 years' worth of payroll taxes! In order to avoid that, you want to minimize any benefits you give them and not control the hours they work, but just that they are fulfilling their duties. I do not require my PA who is an independent contractor to be at the office for a certain amount of hours as long as patients are able to get in to see him quickly. Also, I encourage him to have side gigs as that helps solidify his 1099 status in the IRS’s eyes. Finally, it is key for them to set up their own LLC that you pay instead of them personally. It is definitely a risk to hire practitioners as independent contractors but I think it benefits the practitioner and employer much more than a W-2 employee.

You also need to get a W-9 filled out on anyone that you have paid $600 or more for a service. This could include cleaning companies, lawyers, pest control, painters, plumbers, etc. You can put them in your payroll software like Gusto to then give them their tax documents in January of the next year or your CPA can help process it for you.

For various reasons, over the past several years family physicians have seen their scope of practice dwindle. One such reason is lack of time in their schedule to practice Inpatient or Obstetric medicine. Direct Primary Care allows physicians plenty of time to re-capture a more full-spectrum practice. Many DPC docs take their continuity to the next level by taking care of their patients in the hospital, who can still bill insurance for facility fees (just not professional fees). Many DPC docs deliver babies for a set “global” cash fee, some even practice operative obstetrics.

Reasons many resume inpatient care:

• Value: your patients get more for their money, which helps with recruitment and retention
• DPC docs know their patient better than the hospitalist
• Increases coordination of care and continuity to the outpatient setting
• Doing social rounds? Why not just manage the patient? (Your patients will be texting/calling you from the hospital anyway!)

Barriers to resuming inpatient care:

• Hospital Privileges
  • Easiest to maintain current privileges or obtain out of residency harder to get back
  • May require board certification
  • Occasional turf battles
  • Administrators who don’t understand Medicare Opt-In/Out
  • May require the attendance of Med-Staff meetings, EMR training use, peer review meetings
• Malpractice Insurance may go up
• Some hospitals only give privileges to their own employees (University hospitals, for instance)

Additional barriers to resuming obstetrical care:

• Many have lost the skills after a prolonged absence from OB, could need to be proctored back, refresher courses, ALSO and NRP training, etc.
• Malpractice insurance may go up high enough it wouldn’t offset money made from doing OB, depending on circumstances such as OB numbers, state of practice and OB malpractice rates, etc.

As with many ways of increasing the scope of practice, using social media and the DPCA membership to identify a mentor with experience is invaluable in achieving these goals.