DPCA Articles

When starting your business, you’ll need to make sure to know what falls under federal versus state regulations in running your DPC practice. 

FEDERAL CONSIDERATIONS

Medicare and opt-out issues fall under federal regulation. The rules for opt-out or billing Medicare are the same across the country. 

OSHA is federally regulated. One thing to note is that if you are a solo micro practice with no employees, you do not have to comply with any OSHA standards. OSHA

All relevant federal healthcare laws still apply to DPC.

STATE REGULATIONS

1. Medicaid regulations are state-specific and you will need to find the rules for seeing Medicaid patients under your state laws. There are a handful of states that have an application for “referring and ordering status only,” which makes caring for Medicaid patients a bit easier. As part of the ACA, if you do not actively enroll with Medicaid, you are usually not able to order tests or imaging studies or refer patients to specialists. Despite this, some states are a little more lenient regarding this while others completely ban Medicaid patients from privately contracting with physicians. You should contact your state for their specific regulations before you start seeing Medicaid patients. Check out DPC Frontier for more information on Medicaid.
2. Many states have DPC-specific legislation that protects DPC practices from being treated and governed as insurance. For a list of the laws in your state, see DPC Frontier’s State-by-State guide.
3. Dispensing laws also differ by state, and while most states allow for physician in-office dispensing, several states do not allow dispensing. There are many different types of laws regarding how you dispense, whether you need a permit or need to register, and who is allowed to dispense (MD/DO vs. all providers). DPC Frontier has guidance on dispensing medications here.

Laws vary by state. As of 2021, 19 states have “direct billing laws,” 8 states have anti-mark up laws, and 16 states have disclosure laws. “Direct billing” means that the lab is required to directly bill the patient and may not bill the primary care physician (which would be “client billing”). Unfortunately, this often means that the patient receives an inflated bill. In states with disclosure laws, you must alert patients, either on your website or on your billing, that your wholesale costs are available to them upon request. Read more on pathology services on DPC Frontier.

1) How long does it take to open a DPC practice?

As the saying goes, “If you’ve seen one DPC, you’ve seen one DPC.” There are so many variables that influence this timeline. If a doctor is starting out her DPC only making housecalls, she only needs to set up the legal end of the business and dust off her doctor bag. Theoretically such a practice could open in a month. If a doctor decides to build a 3,000 square foot clinic from the ground up, hire staff, etc. it could take a year or two. Obviously, the average would fall somewhere in between. Many docs begin planning their DPC while still working inside the system in their free time, so the process can get a bit protracted. Conversely, some docs have given 3 months notice at their employed position, and the thought of having zero income in 90 days is highly motivational to get everything done!

2) How do you estimate costs and a break even point?

This is relatively basic math. Do your homework to discern what your expenses will be. Add up your monthly expenses. Divide that by your monthly fee (if you know what your fee will be and it’s inflexible) which will tell you how many patients will break you even. Or divide it by the number of patients you’re willing to take (if it’s inflexible) and that will tell you what your monthly fee needs to be to break even.

3) How do you know you are ready to open your doors?

Nobody’s ever perfectly ready! There’s always something else to get ready, there’s always something you forgot, and there’s always something you have yet to learn. Do the basics. Read all you can. Get a mentor. Then go for it. You will learn/change/grow in so many ways as you go. Sometimes you really have to just go for it. Within reason, of course you shouldn’t fail to do as much homework as you can before you start. The fact that you’re here reading this means you’re doing exactly that!

4) How do you advertise/find patients for your practice?

This is widely variable among DPC practices. The most common thread in the DPC community –by far– is word of mouth. DPC doctors give a level of care, access, and quality that so starkly contrasts with what patients are used to inside the system, that patients can’t help but tell others. Many DPC physicians maintain an advertising budget of $0 because of the success of word of mouth. That being said, in some markets, it’s more difficult to build even that initial small panel of patients who then become your word of mouth advertisers, so advertising/marketing campaigns will help get things started. These doctors have used a variety of advertising strategies, including Radio, TV, Newspaper, etc. In-general, the most effective strategy (which is time-intensive) is pounding the pavement to talk to groups like chamber of commerce, Business Networking International, going around to clubs, church groups, etc. The mantra for this is “If you’re bored, you’re doing it wrong.” The most cost-effective seems to be social media advertising, which might be lower-yield, but can be low-cost.

5) How do you outfit your office on a low budget?

It’s definitely important to keep your overhead down in DPC, and that can be hard to do, because in the medical world, prices are artificially inflated. DPC docs have numerous “hacks” for keeping overhead down, which include finding used equipment from clinics that are closing, using craigslist, auctions, getting used autoclaves from tattoo parlors, you name it. In-general, don’t buy new equipment, because medical equipment depreciation is massive and you can get “like-new” and hospital surplus equipment for a fraction of the price of new–often free. Check out this LINK for tips on keeping overhead down.

6) If you are transitioning, how many patients should you expect to follow you?

Most DPC docs will tell you that about 10-15% of your patients will follow you, and you can’t predict which ones they will be.

5) How do you outfit your office on a low budget?

It’s definitely important to keep your overhead down in DPC, and that can be hard to do, because in the medical world, prices are artificially inflated. DPC docs have numerous “hacks” for keeping overhead down, which include finding used equipment from clinics that are closing, using craigslist, auctions, getting used autoclaves from tattoo parlors, you name it. In-general, don’t buy new equipment, because medical equipment depreciation is massive and you can get “like-new” and hospital surplus equipment for a fraction of the price of new–often free. Check out this LINK for tips on keeping overhead down.

7) How do you determine pricing structure?

Most DPC docs start off by looking at how other comparable DPC clinics (in comparable areas, comparable services, etc.) set prices, and start there. Three other variables are relevant here, which are the following questions: 1) How much money do you need to make? 2) How much do you want to make? 3) How much money will patients pay you? The latter is the most important of course, and if patients in your market won’t pay enough to generate the amount you need, or you’re unwilling to accept the amount you need in place of what you want, then you’ll have to evaluate how big of a panel you can handle.

8) How do you set up labs, imaging, and a referral network?

One way to quickly get this kind of stuff is to join up with other regional DPC doctors who may have already negotiated great deals with imaging centers, labs, etc. Sometimes your EMR vendor might have similar relationships with labs for discounted rates. Or, do the groundwork yourself. Make a meeting with the imaging center owners, the regional Quest or Labcorp office, and build a cash-only price list with vendors for your patients, from the ground up.

9) How does a micropractice handle patient messages during office hours (when you are with another patient)?

Get your patients used to asynchronous communication as much as possible (e-mail and text). If they realize you reply to texts/emails way sooner than answering voicemail, they’ll use what gets them the most prompt reply. If you want it to, your practice will grow to the point where you really will need help if you wish to maximize your efficiency, and paying somebody who can answer the phone and do basic family medicine triage will be a worthwhile investment.

10) What are the biggest obstacles to success in a DPC?

Motivation and work ethic are paramount. DPC is a career-saving model for most doctors in the community, but should not be considered “easy”. You’re still a doctor and that’s never been an easy career. Doctors who set overly-strict boundaries will often fail to grow due to a poor value proposition. The flip side of that coin can be equally problematic; if a doctor sets zero boundaries, their patients may abuse them and burn them out. Another obstacle might be finances. Like any new business, a DPC practice takes time to grow and become profitable. If a doctor expects to make a ton of money and isn’t willing/able to change lifestyle while building the business, they may find themselves doing too much moonlighting, or getting deep in debt.

11) How much staff does a DPC doctor need?

Staff needs are highly dependent on practice size, and services. Some DPC docs start off as a solo micropractice, and slowly add staff as they need help. Others start with a nurse on day one, and then add additional staff. An average mature single-doctor, full-panel DPC practice would usually average 1 to 1.5 employees. Likewise, a larger practice with 3 full-panel full time docs might have 5 people on staff. Full-time staff that DPC doctors employ as they grow usually include nurses, medical assistants, and a business manager. Part time/contract labor that some DPC doctors might use might eventually include housekeepers, pharmacy techs, medical assistants, accountants, lawyers, etc. Some DPC doctors also use part-time virtual assistants as well.

12) What does DPC work day and work week look like?

This is highly dependent on the preferences of the physician and needs/preferences of patients. Most DPC docs work a stereotypical 9-5 M-F work week. When ramping up, it’s not uncommon for doctors to do “top-down” scheduling and take off in the afternoon, etc. Hours get longer as the practice grows. Many docs will take a day off every week or a half day off, etc. if it works for their practice size and doesn’t overly-restrict access for patients. Ultimately, a DPC doc can make their own schedule, as long as they stay within the boundaries of what patients consider to still be a good value for their money.

13) How do you fund your retirement accounts as a solo DPC doctor?

Speak with your financial advisor about this. There are plenty of options to self-fund IRA’s etc. You don’t have to work for somebody else to contribute to retirement accounts.

14) Where can a doctor find more information?

The DPC Alliance maintains the Direct Primary Care University, an online knowledge database. Some of the information there is free to anyone, and much of it is premium content available only to DPCA members. We encourage you to join the Alliance to take advantage of all the benefits of membership, including access to the complete knowledge database. Visit the DPC University

As mentioned in our Boundaries article, having clear guidelines on how your patients should communicate with you is essential. If you are the type of person who loves texting, you may want to encourage your patients to text you with questions.  If you hate texting, you might encourage email instead.  If you anticipate having staff right from the start, you may want to encourage calls to the office during business hours but texting to your cell after hours.  Be realistic about what would work well for you, and make sure you communicate this with your patients at their intake appointment.  

Many physicians will give out or incorporate their policy into their patient agreements, provide a 1 page handout of their policy to new patients, or provide a card with their policy.  Below you will find a sample copy of a card used by one of our physicians as well as a sample 1 page policy.

Do I have what it takes to start a DPC practice?

Entrepreneurs have a vision and are willing to take risks and prepared to work hard. They prefer autonomy over stability. Direct primary care physicians have a persistent passion for patient care. Do you have both? Are you ‘wired’ to be employed? Are you ‘wired’ for autonomy? If a DPC-oriented business offered you a job tomorrow, would that make more sense to you?

Do I still love medicine?

Stop now and answer this question:

Is it time for you to quit medicine altogether or do you still love the work of being a physician but can no longer tolerate your job?

DPC is not the easy path - you will still work hard. It is different in that you are working for yourself and your patient and building something for your future. This inherently restores the autonomy and joy of being a physician, and leads to immense self-growth, and developing new non-clinical skills.

I went to medical school, not business school - how do I start my own business?

Most business owners have not gone to business school either - many may not have gone to college. Running a small business is hard work but not very complicated. If you can become a physician, you can run a business. Check out small business resources from U.S. Small Business Administration.

What do I want my DPC practice to look like?

When deciding what kind of practice to start it is helpful to consider:

• What do you want to build? A small solo practice with just you and your patients? A multi-provider practice? A business you can eventually sell or step away from?
• What resources do you have? Do you need to/want to share them with another doctor?
• How important is autonomy to you?
• What is my ideal patient?
• What niche do I enjoy the most?
• Does it make sense to continue to support an insurance-based practice while trying to grow/build a DPC? (See Risk and Benefits of Hybrid DPC Practice for additional information)
• Do you want to fully separate from insurance billing? Can you do so? (See Terminating Insurance Contracts for additional information)

Regarding employee benefits, you can do whatever you like (within reason and the law). It is not a requirement to offer benefits, but it can be a great way to show your employees how much you appreciate them. You may also want to consider speaking with your accountant regarding financial strategies for your particular situation. Great staff creates a great clinic.

Things to consider:

• Retirement savings
  • Talk to your accountant. Options will depend on your tax structure. Also very strict rules on what can be offered to some but not all employees. What you can do for yourself without involving the same for employees. Definitely use your accountant’s expertise here.
• Health insurance
  • You can sign up for traditional PPO small business health insurance at any time. Find a local broker to learn about more options.
  • Consider giving a set cash amount per pay period, month, or year that your employee can put toward their insurance/healthcare. Seek accountant advice again. Some things are taxed vs tax deductible, etc.
  • Health cost-sharing options such as Sedera or Samaritan ministries. There are many options – google.
• Dental/Vision insurance
  • You can offer the actual insurance, or consider bartering with a local dentist and optometrist to provide annual screening or other discounts for your employees. This could be an opportunity to encourage the other party to consider a membership option. For example, ask if they would consider X dollars for two teeth cleanings, fluoride, and X-rays per year or some other package. Teach these professionals what you do. They may be interested in the model as well.
• Other insurance
  • Disability, life, etc.
• Profit-sharing
  • Variety of ways you could do this. Consider a bonus if it helps sign up new patients. Or a bonus for every 100 patients enrolled. Get creative. Your staff is a very important part of the business and its growth – help them feel valued as such.
• Vacation
  • You are not required to provide paid vacation time, but it’s a perk to consider.
  • Most full-time employees will expect 1-2wk/yr of paid vacation
  • You do not have to provide PAID vacation, holiday, or sick leave
• Days off
  • You must give time off to serve on a jury and perform military service. You may have to give time off to vote (state by state requirement)
  • Consider calling them “Earned Time Off” or “Personal Days” as your staff may have children and need to take time off for them, not just their own sick days.
• Flexibility
  • Many DPC docs love the flexibility that this model provides them in terms of their work schedule. Your staff can also benefit. They can still answer the phone from home when they have to leave early to pick up a sick kid. Again, get creative and find ways to allow your staff to have some flexibility too. But don’t let your staff abuse this.
• You must:
  • Give time off to vote (state by state), serve on a jury, and perform military service.
  • Comply with workers’ comp (see your state laws)
  • Withhold FICA taxes (see your accountant for specifics)
  • Pay state and federal unemployment taxes
  • Company with Federal Family and Medical Leave (FMLA)
  • Contribute to any other state programs such as short-term disability (talk to your accountant)

A final concept on benefits to consider: Within the laws of your state and rules you have to follow based on your location, recognize that each employee or group of employees may not need or want the SAME benefit. For example, one employee may be a divorced mom that has health coverage from her ex but be more interested in a few more paid days off in case of a child’s illness. Another employee may have military benefits and prefer a little more in their paycheck or a bonus of some kind. Another employee may thrive from some recognition like a special birthday gift or award. Ultimately don’t assume you know what they want or need. They very well may prefer some benefit that you wouldn't consider beneficial or preferred yourself. If you give them health insurance that costs $400 per month and what they would prefer is 5 more paid days off per year which would cost you $800 per year … you cost yourself a lot more for a benefit they appreciate a lot less.

Many states now require electronic prescribing (eRx), at least for controlled substances. eRx laws are different in all states. Almost all EMR’s used most often in the DPC community either have electronic prescribing built in, or they have 3rd party arrangements with eRx companies so you can eRx from the EMR.  In all of these cases, the EMR company will have all the information and customer service you might need to set up your eRx account.

Electronic prescribing can also be done outside of an EMR, through separate standalone apps/software/websites.  However in these cases, any prescribing you do through them wouldn’t be recorded in the EMR, so such arrangements are typically only used by those rare DPC physicians who still do paper record-keeping, but need to eRx to be compliant with prescribing laws.

IDENTITY VERIFICATION FOR SETTING UP ERX

When setting up an electronic prescribing platform, the eRx company has to verify the physician’s identity and credentials. This is usually done through credit bureaus, who offer that service. Be warned: if you have had credit freezes for any reason (i.e. fraud, freezes due to travel you name it) the online identity verification process will fail. When it does, the process becomes painfully slow to verify identity, and can require snail-mailing photocopies of your driver’s license, and other rage-inducing demands.  For this reason, if you’re planning to set up eRx in the near future, it’s a good idea to call one of the credit bureaus and make sure your credit report is free of any holds, freezes, or other issues or obtain your free annual credit report to verify no holds or freezes. 

GETTING YOUR DONGLE

When you e-prescribe controlled substances, a 2-step verification process is required, regardless of which system you use.  They will send you a little keychain dongle thing that has a button and digital readout on it.  When you push the button it generates a 6-digit number that has to be entered to complete the controlled rx.  There are also websites and smartphone apps that generate the codes as well. It’s a good idea to set up your eRx software to work with the online app or the phone app in addition to the dongle the company will send you, in case you find yourself away from the office and need to eRx for a patient and don’t have the dongle with you.

DPC vs. Concierge

Direct Primary Care (DPC) and Concierge Medicine are often confused. Both models accept payments directly from their patients, both have smaller panel sizes (allowing for improved relationships with patients), and both tend to advocate for advanced communication between the doctor and patient (via text, email, after-hours calls, virtual visits, etc.).  To make matters even more confusing, some practices that follow a DPC model will advertise as “concierge” for brand recognition. So how, then, is one to know the difference?

If you look closely at the standard DPC setup and compare it to the standard Concierge set up, there are a few key differences:

1. The “Membership Fee”. In concierge practices, the membership fee is traditionally an annual fee; In DPC, your membership fee is traditionally a fee charged monthly, quarterly, or annually.
2. Average Membership Cost. Concierge doctors often charge more in annual fees than the average DPC doctor. Although the average fee is around $1,800 a year, some concierge practices charge as much as $25,000 annually! DPC fees typically range from $600 to $1,500 per year.
3. Insurance. Generally, concierge doctors also accept insurance; in addition to the annual fee, they bill insurance for each patient encounter.  This means that patients may get “surprise bills” several months later after insurance pays their portion (of an amount typically not revealed to you until you get your bill). With DPC, insurance is not billed.
4. Copays. With concierge, because they accept and bill insurance, they are required to collect copays at each visit.  DPC clinics do not bill insurance, so there are no required copays for each visit. (That said, there are some exceptions to this rule as some practices charge a “per visit” fee.)
5. Patient panel size. Both concierge and DPC traditionally maintain a patient panel of 600 patients or less. This enables both provider types to have longer, more in-depth appointments with their patients, and a deeper, more satisfying relationship between doctor and patient.
6. Insurance Regulation. Because concierge doctors typically bill insurance, they are held to several insurance regulations including MACRA/MIPS and other documentation requirements. Since DPC does not bill insurance, they are not required to follow these regulations, enabling the physician to document more efficiently and not waste their time with checkbox documentation.
7. Office overhead costs. Concierge physicians typically have higher overhead costs, owed in large part to their acceptance of insurance which is required to negotiate insurance contracts, bill insurance, process insurance payments, and then resubmit bills when the insurance fails to pay in a timely fashion (which happens all the time). Since DPC physicians do not bill insurance, they do not require staffing and overhead to manage these revenue cycles, resulting in lower overhead.
8. Culture: Concierge practices often market services like “advanced testing” or more customer experience services like special parking spaces to justify their memberships. DPC practices focus more on care navigation and price transparency.

Direct Primary Care patients pay a set fee per month. This can be thought of as the physician receiving a set payment per member per month (“PMPM”) -- a term often associated with capitation. Capitation gained popularity with the rise of HMOs in the 1990s as a payment model which would, theoretically, help curb healthcare costs. With capitation, insurance companies pay physicians a set amount per patient per month. The more care the patient receives, the less money remains for the physician at the end of the month. While DPC and capitation share a set amount of money per patient per month, the payer and underlying psychology set the two models widely apart.

Capitation, in its original form, is rarely seen at this point due to people exploiting the model. Since the payer was insurance, the physician had no fiscal responsibility to the patient and as such only needed to play the “game” according to the rules set by the insurance company. The rules of the game allowed maximization of income by minimization of patient interaction. Patients found themselves shut out by physicians, having an increasingly hard time making appointments or noticing the quality of the physician’s office declining significantly.

DPC fundamentally changes the rules by making the payer the patient rather than a third party. The financial risks and benefits now tie directly to patient care. Should the patient find the physician to not meet their needs, they will go elsewhere, and the physician has no guarantee that another patient will fill their spot. In addition, incentives are aligned in keeping the patient healthy and out of the office.

The capitation model lends itself to abuse. DPC gives little room, if any, for abuse, because the interests of patient and physician are aligned.

While capitation and DPC can be made to sound the same, the fundamental difference, the core of DPC, is the direct relationship, medical and financial, between the patient and physician.

As a cost-reducing model, DPC intuitively helps those who have a hard time affording care in the current model; yet to many who are involved in healthcare policy, the idea of paying the physician directly sounds like an added cost to patients and detrimental to a group often collectively called “the poor” or "the underprivileged". Within this group, there are a few subgroups to identify to help show how DPC can be beneficial to "the underprivileged".

HEAVY UTILIZERS - Patients requiring frequent visits 

• Decreased need for a more costly "low deductible" plan
• Decreased costs for multiple medication regimes
• Longer visits at more frequent intervals
• The DPC physician acts as one central advocate to help coordinate their specialist and hospital needs. 
• More engagement in their treatment plan due to having a stronger physician-patient relationship
• Decreased anxiety because they can easily reach their physician who knows their history
• Fewer referrals compared to fee for service referral mill practices

WORKING CLASS - patients that cannot afford insurance and do not qualify for government subsidies or safety net insurance. 

• These patients ignore health problems often for years because it is so expensive for them to get routine monitoring.
• Chronic disease monitoring and preventive health monitoring at an affordable price tends to lead to fewer complications with better disease control and decreased ER visits
• DPC allows these patients the freedom to see their doctor before small problems become complicated

GOVERNMENT INSURANCE - Medicare, Tricare, and Medicaid eligible patients 

• Many physicians do not accept Medicaid patients due to poor reimbursement. These patients have coverage but may not be getting the best CARE, especially with long wait times, 5-minute visits, and only partial coverage services.
• Medicare patients often join your practice for the increased access and longer visits with more detail to their care.  

UNINSURED/UNDOCUMENTED

• Many DPC physicians waive their fees or set up private charity funds to help care for those who cannot afford the monthly fees
• Most physicians went into medicine to help people and have large philanthropic hearts. DPC allows you to do what you think is the right thing for your patients, giving you back control over how you live your life and practice medicine.
• Caveat: Learn to differentiate those patients who really need your help from those who can afford it but do not respect the membership or you enough to pay a reasonable monthly fee. Set your boundaries, and stick to them.

DPC exists to take care of primary care services which do not make sense to finance through insurance. People do not use their car insurance for oil changes or filling up gas. In healthcare, people shouldn’t use health insurance for chronic disease or basic urgent care. Although Direct Primary Care physicians do not accept or bill insurance, patients can still opt to use insurance for ancillary services. Most insurance products will still recognize and accept an order from out-of-network physicians (ie DPC physicians). Exceptions include:

• Medicare Advantage Plans
• HMO's
• Medicaid (state-dependent)

This means that if a patient chooses to, they can utilize their insurance for:

• Imaging
• Medications
• Lab work
• Specialist or ancillary services referrals

CONVENTIONAL INSURANCE:

Many insurances require per-certification or prior authorization for certain imaging or medications. Suggestion: when ordering what may be an expensive test/medication, give the patient an order/prescription and ask them to check with their insurance if/how this will be covered. You may need to give billing or CPT codes for some insurances (which drags you back to your system days once in a while and makes you appreciate the daily simplicity of your DPC life!).

HIGH DEDUCTIBLE PLANS:

It is often less expensive for the patient to pay cash for the test if they have a high deductible, which saves them money, and your time. It is worth having this discussion with your patient:

“I’d like to order an MRI of your knee. What is your insurance plan and what is your deductible? How much of your deductible have you met this year?”

Usual answer: “I don’t know my deductible, and I don’t know how much I have met”.

Empower the patient - give them some homework and a cost-saving carrot to entice them to do it.

“Well, I don’t anticipate this is going to need an expensive surgery and you are generally healthy. MRI of the knee would cost you around $400 at this location. If you go through your insurance with a high deductible that you have not met, it may cost around $3000-4000. It is your choice which way you would like to proceed.”

End result: Patient learns more about how their insurance works, they have been part of the cost-saving solution and feel empowered by that, and you have written an MRI order for a cash pay location without time wasted on precertification. WIN WIN WIN.

MEDICATIONS:

You may consider the same tactic with medication dispensing.

“Your medication costs $10/months through our pharmacy and $13/month paying cash with GoodRx. Why don’t we send the first month to the pharmacy, let them run your insurance and see which option is most cost-effective.”

The more your patients understand about the cost savings and the different options that they have, the more that they become invested in the Direct Primary Care model and are likely to spread the word, marketing for you.

MANAGED CARE/HMO

This one gets tricky. You must be upfront with an HMO patient. You cannot write referrals for them and they need to have an In-network PCP to do that. Some DPC physicians develop relationships with local HMO network physicians who are happy to see their patients for referrals and take a backseat while collecting the monthly capitation (with less work). Others are not. Here are some options if you decide to take HMO patients.

• Co-manage a patient with their in-network PCP
• Patients pay cash for all their services (less expensive if the deductible is high)
• Not accepting managed care patients at all

MEDICAID:

Although Medicaid can be an exception, this is state-dependent. In some states, it is illegal for Medicaid patients to pay cash to see a doctor. In other states, Medicaid has an “ordering and referring provider” status that the physician can apply for which would enable Medicaid to honor their medication and imaging orders. As this is state-specific, the best advice would be the check with physicians practicing in your state or check dpcfrontier.com for state-by-state regulations.

See Federal and State Regulations here.

MEDICARE:

It is illegal to be a medicare provider and charge cash for services that Medicare covers (Medicare fraud). Please see Working with Medicare - The Basics, and Medicare: Opting In or Out for more details.

Consider carefully the major technology investments in your practice for your EMR [link], billing service, and VOIP phone service https://www.dpcalliance.org/DPCU-Practice-Management-Patient#ComparisonOfVOIP.[see "Practice Software & Communications" section in the STARTING A DPC PRACTICE CHECKLIST]Besides these, below are helpful tools. Check your EMR if any are offered already or may be integrated. Also, don't forget to check for discounts for DPCA members[LINK].Telehealth (HIPAA compliant): doxy.meMedical Dictation Software: Dragon[LINK]Text to Speech softwareText Expansion tools: https://textexpander.com/ , breevy, https://www.phraseexpress.com/Team & Task Management: https://slack.com/Document Management: https://www.ilovepdf.com/, https://intakeq.com/, https://www.hellosign.com/ , https://www.jotform.com/, https://signaturely.com/, https://www.docusign.com/en-us/Video Creation software i.e. for patient education: https://www.loom.com/Password Manager: https://www.dashlane.com/ , https://1password.com/, https://www.lastpass.com/

The U.S. Department of Labor (DOL) is a department of the federal government that exists to ensure fair, safe, and healthy working conditions for employees by maintaining and enforcing federal laws regarding minimum hourly wage and overtime pay, protection against employee discrimination and unemployment insurance. 

The federal minimum wage is $7.25 per hour effective July 24, 2009. There are also state minimum wage laws and in cases where this differs, the employee is entitled to the higher minimum wage.

Covered, nonexempt employees must receive overtime pay for hours worked over 40 per workweek at a rate not less than 1 ½  times the regular rate of pay. There is no limit on the number of hours employees over 16 years of age may work per workweek. There is no requirement to give overtime pay on weekends, holidays or regular days of rest unless overtime is worked on those days.

Under the Fair Labor Standards Act (FLSA), in order to provide a set salary, employees must meet the following criteria:

1. The employee must be paid a predetermined and fixed salary that is not subject to reduction based on variations in hours worked.
2. The amount of salary paid must meet a minimum specified amount (“salary level test”). Currently the standard salary level is $684 per week ($35,568 per year). Under the new rule from 2019, the employer may use non-discretionary bonuses and incentive payments (including commissions) to satisfy up to 10% of the standard salary level.
3. The employee’s job duties must primarily involve executive, administrative, or professional duties as defined by the regulations (“duties test”).

The DOL rules implementing the FLSA specifically categorize LPNs and LVNs as non-exempt, meaning they cannot be salaried and must be paid overtime. RNs may be considered exempt if they are paid at least $684 per week, and they meet the duty requirement for the learned professional exemption. Employers should also familiarize themselves with their local state laws, as they can sometimes differ from the Federal requirements.

In addition, an official poster outlining the requirements of the Fair Labor Standards Act must be displayed at the place of work.

Employers should keep in mind that the U.S. Department of Labor (DOL) can audit employers at any time, although the most common reason for an audit is a complaint from an employee. The DOL has also targeted employers in low-wage industries for wage and hour violations, particularly in the areas of agriculture, day care, food service, garment manufacturing, guard services, health care, hotels and motels, janitorial services and temporary help. By understanding the audit process and following the guidance below, employers will be better prepared for a DOL audit.

The DOL typically provides little advance notice of an audit. However, you can request time to gather records. Typically, the amount of time an employer will have will depend on the auditor.

Contact the auditor to find out specific information about the audit. Key questions to ask are the focus of the investigation (e.g., overtime pay compliance, exempt vs. nonexempt classification, minimum wage compliance), the time period for records the auditor wants to review, and the names of any employees that may be interviewed.

• Gather the records in accordance with guidance provided by the auditor.
• Be prepared to provide documentation related to the company compensation policies and procedures.
• Keep track of exactly what information was provided. Do not provide records other than what the auditor requests.
• Designate a company representative to work with the auditor. Some employers choose to designate their company’s legal counsel; other employers will designate senior managers. The representatives will have the duty to provide documents requested, arrange for any additional records to be provided to the auditor (if necessary) and coordinate employee interviews.

During the audit, be courteous to and cooperative with the auditor. It is a good practice to provide a quiet area for the auditor to work in.

At the end of the audit, ask the auditor to provide a summary of the results of the investigation. This information will help an employer review options for resolutions if any violations are found. If violations are found, employers are encouraged to consult legal counsel before any settlements are reached with the DOL.

To be proactive, employers should consider a self-audit, which consists of the following steps:

• Review job descriptions.
• Understand both federal and state law and ensure the employer is in compliance.
• Ensure that FLSA classifications are correct.
• Keep accurate payroll records.
• Apply policies consistently.
• Make sure all records are complete and work to resolve any inconsistencies.
• Determine how to address any areas of concern identified via the self-audit.

The first official step in opening your practice is to create a legal entity. The regulations surrounding this process vary by state, and it is important to note that even if you are not set on a name, you can choose a name and then later file a “doing business as” (DBA) if you end up choosing a different name. Some opt to do this independently using Legal Zoom or directly with the Secretary of State; others opt to use a lawyer for their entity creation. In Texas, for example, a physician practicing medicine can file their business as a “professional association” (PA) or a “professional limited liability corporation” (PLLC). In other states, a simple LLC is all that is required. Check your state laws for specifics or allow your lawyer or CPA to guide you in what may be required in your state.

Your business type will affect your tax classification. Consider hiring a CPA that understands DPC -- or small business management at a minimum -- to help decide which legal structure is most beneficial for your clinic. The Small Business Administration (SBA) is another highly beneficial resource; you can browse their website or set up a (free!) business coaching session locally.

There are several IRS business structures to choose from.

• Sole proprietorship
• Partnership
• Corporation
  • S-Corp
  • C-Corp
• Limited Liability Company (LLC)

You’ll want to review the differences between these at length before selecting one. Most DPC practices start as an LLC. Your business structure affects how you pay taxes, raise capital, and even your personal liability. As your business evolves, your structure may change.

After you choose a structure, you will file for a federal tax ID number (FEIN or EIN). It’s free to apply and simple to do. You will need your EIN before you can apply for a business bank account, credit card, any business licenses, permits, etc. You will also need it when you sign up for vendors such as pharmacy wholesalers and medical supply companies. Do not delay this step

If you don't want to wear ALL the hats, then having a micropractice is not for you.

A micropractice clinic essentially has no staff; you are the receptionist, data entry clerk, biller, contract reviewer, inventory & supply manager, nurse, MA, office manager...and physician.

WHY

So why would you consider having a micropractice?

You're just starting out

To save on payroll & tax

To avoid HR issues & have complete control and compliance on office policies

To communicate with patients directly and succinctly

To have more flexibility i.e. having a part-time schedule, have a telemedicine-heavy practice

You're financially OK with a smallish patient panel

HOW

Follow STARTING A DPC PRACTICE CHECKLIST 

SPECIAL CONSIDERATIONS for the Micropractice:

It's very important to set patient expectations up front about your available hours and how patients may communicate with you.

Will you allow non-secure emails & texts?

Have this in your patient Agreement and / or a welcome FAQ handout.

OFFICE HOURS

Based on personal or family needs, do you want 2 hr lunches/ admin time? a half-day off? extended early morning or late evening hours?

OFFICE SPACE

How much space do you actually need?

Do you want the public to know (on your website or social media) that you have no staff?

Install extra security features in your clinic & surroundings.

GROUP MEMBERSHIPS

On-boarding new members of a group is more time intensive initially.

EFFICIENCY

Automate. Automate. Automate.

Maximize tech tools to your benefit

Get a robust EMR system with integrated fax & eRX and patient portal.

Patient portal self service includes scheduling, bill pay, encounter summaries, refill requests, documents, secure messaging.

ADMIN DUTIES

Create admin duties for front & back office staff (should you later hire for these positions), and how often they need to be done.

Block recurrent times on the schedule for these duties.

EXTRA SERVICES

You may or not want to provide and fit these into your schedule, without assistance:

Housecalls

Medication dispensing

Phlebotomy

PFT / diagnostic testing/ POCUS

Aesthetics

ROLES to OUTSOURCE, or not

Housekeeper

Landscaper

Bookkeeper

Contract reviews

Marketing

WHEN IS IT TIME TO TRANSITION?

Set your criteria to close your panel or add staff or a partner, i.e. when you're unable to respond to patients' needs within 48-72 hrs?

Or you find someone you can depend on 100% to hire.

VARIATIONS on the Micropractice:

micropractice with a Virtual Assistant

micropractice in a group practice (physicians only and no staff)

Traditional telephone service or “plain old telephone service” uses physical wires to connect phone calls between locations. This technology hasn’t changed much in the past century which has created challenges for businesses.

Voice over Internet Protocol (VOIP) eliminates the limitations of a physical phone line by connecting calls over any internet connection. This offers greater flexibility and can substantially lower costs.

Plain old telephone service (POTS)

Advantages

Perhaps the greatest advantage of a “landline” or “plain old telephone service” is reliability particularly when your internet service is slow, faulty, or “goes down”. Plain old telephone service often functions despite power outages.

Disadvantages

One of the biggest reasons companies are steering away from traditional landlines is that landline services are significantly more expensive than VOIP services. Installation and ongoing costs are remarkably higher than VOIP.

Another disadvantage to landline services is the lack of features in comparison to VOIP. Landlines are limited to audio communication, so video conferencing is not an option nor is hold music, call recording, analytics, or SMS.

Voice over IP (VOIP)

Advantages

Perhaps the most appealing factor of VOIP is that it is very cost-effective and a cheaper solution when compared to regular telephone systems. The only additional cost to obtaining a VOIP service is internet installation; however, if you already have active internet service, then the cost of adding on a VOIP system is small.

Additionally, VOIP systems generally come with additional features at no added cost such as call waiting, call parking, call forwarding, conference calling, multimedia communications, auto-attendants, and voicemail to text or email messaging, not to mention integration with customer relationship management (CRM) tools, project management applications, and email marketing software

Disadvantages

The main disadvantage of using VOIP is that you need to have a stable internet connection. Although the bandwidth requirement for VOIP calls is incredibly low (10-32 kbps), other resource-heavy applications can affect the overall quality of your VOIP calls. To offset this, many businesses and organizations institute quality of service (QoS) feature on their computer network to prioritize bandwidth resources.

In light of potential power outages, a disadvantage to VOIP is that unless calls are routed to a secondary device (oftentimes a mobile phone), it will not be possible to make or receive phone calls during a blackout.

Clinical Laboratory Improvement Amendments, or CLIA, are made up of three federal agencies: The Food and Drug Administration (FDA), Center for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC). 

The FDA categorizes tests based on complexity, reviews requests for Waiver by Application (for companies applying for their test to be waived), and develops rules and regulations for CLIA complexity categorization. 

CMS issues laboratory certificates, collects user fees, conducts inspections, enforces regulatory compliance, monitors lab performance on Proficiency Testing, approves Proficiency Testing programs, and publishes CLIA rules and regulations. 

The CDC provides analysis, research, and technical assistance, develops technical standards and lab practice guidelines, conducts lab quality improvement studies, monitors proficiency testing practices, educates professionals and provides resources, and manages the CLIA advisory committee (CLIAC). 

Below is an excerpt from the Q&A section of CMS regarding CLIA and how to obtain a certificate of waiver for your practice (please note that in some states there may be a separate application/process): 

What is a laboratory? 

Under CLIA, a laboratory is defined as a facility that performs applicable testing on materials derived from the human body for the purpose of diagnosis, prevention, or treatment of any disease, impairment, or assessment of health of human beings. 

I am a physician performing urine dip sticks and finger sticks for blood glucose in my office as part of the patient’s visit. Am I considered to have a laboratory and do I need a CLIA certificate?

Generally yes, as those tests likely qualify as waived laboratory

testing, you need a CLIA Certificate of Waiver and you must follow the manufacturer’s instructions. This kind of testing requires a CLIA certificate regardless of how many tests you perform, even if you do not charge the patient or bill Medicare or other insurances. However, you may not need a CLIA certificate if your laboratory is located in the states of New York or Washington, as those States operate their own laboratory regulatory programs. Contact the appropriate State Agency to determine if you need a CLIA certificate.

What is a waived test?

As defined by CLIA, waived tests are categorized as “simple laboratory examinations and procedures that have an insignificant risk of an erroneous result.” The Food and Drug Administration (FDA) determines which tests meet these criteria when it reviews manufacturer’s applications for test system waiver.

Where can I find a list of waived tests?

For a list of waived tests sorted by analyte name, visit the FDA website at:

CLIA – Currently Waived Analytes

Can I perform tests other than waived tests if I have a Certificate of Waiver?

No, only those tests that are CLIA-waived can be performed by a laboratory with a Certificate of Waiver.

How do I enroll in or apply to the CLIA program?

You can enroll your laboratory in the CLIA program by completing an application (Form CMS-116) available on the CMS CLIA website or from your local State Agency. Send your completed application to the address of the local State Agency for the State in which your laboratory is located. Additionally, check with your State Agency for any other state-specific requirements. If you do not have online access and do not have information about your State Agency, you may contact the CLIA program at 410-786-3531 for the address and phone number of your State Agency.

If I have more than one office and perform waived testing at more than one site, do I need additional certificates?

You will need a CLIA certificate for each site where you perform testing, unless you qualify for one of the exceptions listed below:

• If your testing location changes, such as with mobile units providing laboratory testing, health screening fairs, or other temporary testing locations, the testing may be covered under the certificate of the designated primary site or home base, using its address.
• If you are performing limited public health testing, you may file a single application to cover multiple locations. Limited public health testing is defined as not-for-profit or Federal, State or local government laboratories that engage in limited testing (not more than a combination of 15 moderately complex* or waived tests per certificate). So you may be able to cover the waived testing you perform at more than one office if you meet this exception.
• If your testing locations are within a hospital and are located at contiguous buildings on the same campus and under common direction, you may file a single application for the laboratory sites within the same physical location or street address.

Contact your State Agency if you have questions or you are filing a single application for more than one testing site.

Will I receive an identifying CLIA number?

You will receive a ten-character alpha-numeric code on the CLIA certificate. This number will be utilized to identify and track your laboratory throughout its entire history. You should use this number when making inquiries to the State Agency and CMS about your laboratory.

When can I start performing the waived testing?

After you apply for your certificate, you will receive a fee coupon assessing a fee. Follow the instructions on the fee coupon for payment. After your payment is received, your certificate will be mailed to you. You generally may begin testing once you have received your CLIA certificate, but you also need to check with your State Agency, since some states have additional state-law requirements.

If I only perform waived tests, what does CLIA require that I do?

For waived testing, CLIA requires that you:

• Enroll in the CLIA program by obtaining a certificate;
• Pay the certificate fee every two years;
• Follow the manufacturer’s instructions for the waived tests you are performing; and
• Notify your State Agency of any changes in ownership, name, address or Laboratory Director within 30 days, or if you wish to add tests that are more complex.

How and when will I be inspected?

Laboratories with a Certificate of Waiver are not subject to a routine inspection (survey) under the CLIA Program, but may be surveyed in response to a complaint or if they are performing testing that is not waived.

What does it mean to follow the manufacturer’s instructions for performing the test?

To follow the manufacturer’s instructions for performing the test means to follow all of the instructions in the package insert from “intended use” to “limitations of the procedure.” The manufacturer’s instructions can be found in the package insert for each test. It is good laboratory practice and important to read the entire package insert before you begin testing. Be sure the package insert is current for the test system in use, the correct specimen type is used, the proper reagents (testing solutions) are added in the correct order, and the test is performed according to the step by step procedure outlined in the package insert.

Some waived tests also have quick reference instructions included, which are cards or small signs containing diagrams or flow charts with essential steps for conducting the test. Be sure that quick reference instructions are current for the test system in use and are available to the individuals performing the test.

How do I know if I have the current manufacturer’s instructions?

Always use the package insert or quick reference instructions that come with the test system you just opened. If you are unsure whether you have current instructions, contact the manufacturer at the telephone number listed in the package insert.

Why is it important to follow the current manufacturer’s instructions?

It is important to always follow the current test system’s instructions precisely to be sure your results are accurate. This includes performing any quality control procedures that the manufacturer recommends or requires. Over time, a manufacturer may make modifications to a test system that result in changes to the instructions. Failure to use the current instructions could cause inaccurate results that may result in a misdiagnosis or delay in proper treatment of a patient.

Do I need to follow all the manufacturer’s instructions on how to perform the test?

Yes, all the information in the test package insert instructions is considered part of the manufacturer’s instructions and must be followed. Some examples of this information are:

• Observing storage and handling requirements for the test system components;
• Adhering to the expiration date of the test system and reagents, as applicable;
• Performing quality control, as required by the manufacturer;
• Performing function checks and maintenance of equipment;
• Training testing personnel in the performance of the test, if required by the manufacturer;
• Reporting patients’ test results in the units described in the package insert;
• Sending specimens for confirmatory tests, when required by the manufacturer; and
• Ensuring that any test system limitations are observed.

Can I follow the quick reference guide instead of following the package insert?

No, the quick reference guide is only a synopsis of the entire package insert.

When performing waived testing, am I required to do everything in the instructions, even if some of the items are manufacturer’s recommendations or suggestions?

Yes, you must follow all instructions when such terms as “always,” “require,” “shall,” and/or “must” are used by the manufacturer.

You have the option to follow the recommendations or suggestions of the manufacturer. However, adhering to the manufacturer’s recommendations and suggestions will help ensure the accuracy and reliability of the test, and is considered good laboratory practice.

As a laboratory director, what kinds of things can I do to help ensure the accuracy and reliability of the waived testing in my laboratory?

In order to ensure the accuracy and reliability of waived testing in your laboratory, you should develop and maintain good laboratory practices. Some examples are listed below:

• Provide specific training to the testing personnel so that you are certain they:
• Collect specimens appropriately;
• Label and store specimens appropriately;
• Understand and then follow the manufacturer’s instructions for each test performed;
• Know how to perform the testing;
• Know how to document and communicate the test results; and
• Are able to identify inaccurate results or test system failures.
• Observe and evaluate your testing personnel to make certain the testing is accurate.
• Do they positively identify the patient and specimen?
• Do they collect a proper specimen?
• Do they know how the specimen should be preserved, if applicable?
• If the specimen needs to be transported, do your testing personnel understand and adhere to the transport requirements?
• Check for extreme changes in such things as humidity, temperature, or lighting; as these may affect test results.
• Make sure that the patient specimen is handled properly from collection to test completion.

Where can I find more information about good laboratory practices?

The Centers for Disease Control and Prevention has published recommendations for “Good Laboratory Practices for Waived Testing Sites” in Morbidity and Mortality Weekly Reports (MMWR); Recommendations and Reports. The MMWR publication provides comprehensive recommendations for facilities that are considering introducing waived testing or offering a new waived test, and good laboratory practices to be followed before, during, and after testing. You can find this article on the CDC CLIA Waived Testing website.

Additionally, there are free educational materials on waived testing on the CDC Division of Laboratory Systems website.

Can I make any changes to the test system instructions?

No, it is not acceptable for you to make changes to the current instructions provided with the test system. This could change the “intended use” of the test system as approved by FDA and result in a test that is no longer waived. For example, if a test specifies urine as the waived specimen type and you test a different body fluid, then you are no longer performing a waived test and your laboratory is subject to an inspection and additional CLIA requirements. You must be sure that testing personnel follow the directions exactly, and add the proper reagents in the correct order and amount given by the manufacturer to ensure correct test results.

Resources: https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/howobtaincertificateofwaiver.pdf

CDC Guide for waived tests (has free forms and guides for download)

Many direct primary care doctors transition to DPC to move away from creating financial hardship and ruin for their patients. Even so, large, unpaid invoices can pile up into something (in business the invoices you’re expecting to be paid are called your “accounts receivable.”)

After a significant time has passed (usually a specific time window of 90 or 180 days) without payment, some businesses looking to receive payment for unpaid invoices will sell unpaid bills to a collection agency. Collection agencies will often chase after unpaid debt and will keep a certain percent of the eventually collected bills as payment for chasing down the charge. Each agency has a unique contract; if you’re going down this path, just make sure to read and understand the terms of the contract.

Many DPC doctors do not send patients to collections. Some share that it isn’t worth the trouble or potential bad publicity. Others believe that it breeds bad karma (and potentially poor reviews!) that just aren’t worth it in the long run.

TLDR? Collections are a hassle, often a lost cause, and creates bad karma.

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?

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).

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.