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).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

With any of these options, consider the time requirements, scheduling conflicts with DPC clinic time, pay, your existing skillset, malpractice coverage, and whether it requires Medicare participation. Malpractice coverage is required for every clinical position. Make sure you are covered both in your DPC and your moonlighting position and get separate coverage if needed. Regarding time commitments, DPC patients expect good service and part of that is doctor availability. Plan to meet or exceed those expectations, and remember your long-term plan when choosing a side gig. Any option that provides adequate income and fits your skills, interests, and schedule increases your chances of DPC success.

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

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

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

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

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

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

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

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

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

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

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

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

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

Before employees chose your DPC clinic they will have to go through an “open enrollment” process. This process occurs yearly and allows time for benefits advisors and employers to explain all the employee benefits. These are usually long, boring meetings but do offer critical time for employees to ask questions and understand their health plans. Getting involved in this open enrollment process is a must for DPC docs as it is crucial for starting a relationship with employees (and employers -- they will be patients too).

You should ask the employer and the benefits advisor to keep you involved and plan for time off to attend those meetings. Ideally, they will allow you time to speak at open enrollment to share your DPC passion with employees. Plan to be available to answer employee questions at the end of this meeting.

(This will likely blow employers’ and employees’ minds, as they have never had a physician actually come speak to them about anything -- let alone about increasing access to care and lowering costs!)

Open enrollment meetings are a great time to “meet and greet” some potential new patients!

You landed a new employer which potentially could add dozens or hundreds (!) of new patients in a few months, now what? How do you get all those people into your EHR system and into your office for initial visits? Here are some tips:

• Plan ahead for busy schedules (leave open schedules, limit time off)
• Prepare the staff for new patients (add new staff? adjust work hours?)
• Get patients registered In your EHR ASAP (educate employee and employer here)
• Try designing cards to be given to employees with simple directions on how to sign up on the DPC EHR
• Build basic “skeleton” charts for all the patients that did not sign up online
• Schedule initial visits for all employees, as soon as possible -- think about sending reminders via text and/or email to encourage people to come in.
• See sick visits and refills as needed even if initial visits not done
• If possible, don’t onboard in the middle of cold and flu season

Adding lots of new employer patients will be time-consuming but proper planning can be done in a few months. Be sure to let the employer know about your onboarding plans and get involved in the open enrollment sessions to provide clear communication with your future patients is the key.

The diagnosis and treatment of Obstructive Sleep Apnea can be achieved at a more affordable rate through cash pricing.

TESTING:

Home Sleep Apnea Testing (HSAT) services will mail the HSAT equipment to your patient’s home, where the patients hook it up, sleep, and mail it back. Reports are mailed/faxed to your office. Prices are currently as low as $125. Several companies offer this service, and the DPCA has partnerships with two of them, Somno and OwnSleepMed.

TREATMENT:

Auto-CPAP equipment with additional supplies (mask, filters, tubes, etc.) is available for around $600. Also, look for used equipment on sites like eBay.

Note: Patients of DPC Alliance members can get a discount on OSA-related equipment via our Vendor Partnership with TerraCore DPC. This negotiated discount is a member benefit. The DPC Alliance receives no direct financial benefit from any of our vendor partnerships. Learn more about our vendor partnerships here.

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

CONNECT WITH YOUR PATIENTS ONLINE BEFORE YOUR ANNOUNCEMENT:

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

EMPLOYED PHYSICIANS - TRY TO NEGOTIATE NON-SOLICITATION CLAUSE:

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

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

IF SOLICITATION IS PERMITTED - ANNOUNCEMENT(S)

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

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

SPREADING THE WORD IF YOUR NO SOLICITATION IS IRONCLAD

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

NON-COMPETE RADIUS:

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

SAMPLE NOTIFICATION AND TRANSITION LETTERS (DPCA members only)

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

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

Why Dispense?

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

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

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

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

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

How to Dispense

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

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

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

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

A new DPC practice does not typically provide the same income as a traditional practice. When starting a DPC practice--whether out of residency or leaving a traditional or employed practice--a strategy for additional income sources is essential. Having adequate income outside the DPC practice can be the difference between success and failure. Don’t put your ultimate freedom in jeopardy by not having a viable plan. Even if you plan to use loans or savings to subsidize your income, having other possible revenue sources can help if growth is slower or costs are higher than expected.

Do what you know: If you’re already moonlighting in an ER or urgent care--or have before--that’s a natural place to start. If not, there are plenty of options for a primary doctor willing to hustle.

Most DPC doctors are opted out of Medicare. Learn more about opting out of Medicare. Many DPC docs who are doing moonlighting/side hustles will wait until their DPC is more established to opt-out because opted-out moonlighting is more challenging and bamboozles administrators who’ve never had to figure out how to make it work. For those who have opted out of Medicare, DPC Frontier also has a great resource on Opted-out moonlighting, here.

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

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

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

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

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

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

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

There are many different ways to advertise, and what works for one office may not work for another. When developing your marketing plan, the first step is determining who your target audience is. Without defining a target audience, you cannot expect your marketing to have peak success.

The biggest mistake you can make is thinking “my target audience is everyone” because if it is everyone, no one is listening. So, while you may want a variety of patients and want “everyone” as patients, you should not try marketing to “everyone”.

Part of defining the target audience is evaluating what your ideal patient looks like. Is your ideal patient a young married couple with 2-3 kids? Or maybe your ideal patient is a truck driver who is rarely home and likely to utilize remote medicine more heavily than in-office appointments. Or perhaps your ideal patient is the diabetic hypertensive patient who really wants to improve their lifestyle but struggles to keep to a plan.

Although this is not an exhaustive list, some things to consider when determining your target audience include:

1. What kind of medical care do I enjoy the most? Do I really enjoy lifestyle medicine? Do I enjoy making personal connections and being that connection for people whose family has all moved away? Do I enjoy pediatric care and watching my patients grow into adulthood? Identifying what you enjoy will help ensure you will find joy and fulfillment in your practice.
2. Who is around me? If you want to grow a pediatric practice, but are looking to establish near a retirement community, you might want to look elsewhere or change your target audience. If you are unfamiliar with an area, you can usually obtain general demographic information such as age distribution, gender distribution, average income level, average education level, etc from the local Town or City Hall
3. Look at the current customer base. Where are your current, potential patients receiving their care? Look for common characteristics and identify ways you can stand out among the crowd. If you are establishing in an area where there are very few primary care offices, your advertising will be very different than if you are establishing in an area dominated by multiple large well-known medical corporations.
4. Are there any medical services you wish to offer that currently are not offered locally? For instance, if you enjoy cosmetics and there are no obvious cosmetic medical practices, that would be a great asset to really set you apart.
5. What are the personal characteristics of your target audience? Are they stay-at-home parents? Are they avid outdoors people? Your marketing will be very different if you are trying to reach stay-at-home parents than if you wish to reach avid mountain bikers.
6. Where does your local community congregate? Do they all go to churches? Do they congregate on select Facebook Communities? Do they utilize Nextdoor heavily? Is there a local paper that everyone in the neighborhood reads? This information is key to helping you determine where to reach your target audience. For instance, if they are all on Facebook and you are advertising on Nextdoor you will be wasting your time and money.
7. Evaluate your decisions. You’ve made it this far into identifying a target audience, but is that target audience large enough to warrant spending money to advertise to? Or are you likely only going to get a couple of patients over several years out of that audience?

With all that, remember that you can have multiple target audiences for different marketing plans/goals - but each marketing plan should be directed at one target audience for the best effect.

For more information, consider checking out this link, How To Create A Great Elevator Pitch

Sometimes the best or most affordable option is for a patient to travel to receive specialty care, especially for surgery and other procedures. This is commonly referred to as “medical tourism.” In the past, this has implied leaving the US; however, there are several US surgery centers catering to direct-pay patients.

It is valuable but not always necessary to help your patient navigate this process. Your knowledge of medical tourism options can be very reassuring for patients when this feels very different and may be hard for them to consider the idea. Familiarize yourself with large direct pay centers in the US.

A few of these options for patients to consider:

DOMESTIC DIRECT-PAY SURGERY CENTERS

https://www.surgerycenterok.com/ (Oklahoma City, OK)

https://www.affordableherniasurgery.com/ (Rockville, MD)

https://www.oceansurgerycenter.com/specialties-pricing-torrance/ (Torrance, CA)

https://hpbsurgery.net/Pages/pricing/low-cost-surgery-pricing.html (Winston-Salem, NC)

https://texasfreemarketsurgery.com/ (Austin, TX)

https://www.pacificsurgicalwa.com/pricing/ (Longview, WA)

https://lonestarsurgeryctr.com/pricing/ (Houston, TX)

https://omahasurgicalcenter.net/billing-insurance/ (Omaha, NE)

https://www.nttcsurgerycenter.com/ (Mesquite, TX)

https://www.stgeorgesurgical.com/ (St. George, UT)

INTERNATIONAL DIRECT-PAY SURGERY CENTERS

Traveling to another country for surgery or medical care is a more complex matter with a few special considerations. The CDC has some guidance on this topic.

Here is a map

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

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

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

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

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

First and foremost, BE READY!

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

Pre-enrollment

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

Once you have everything ready

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

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

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

Here is a sample process:

From Allison Edwards, MD | Kansas City Direct Primary Care

Clinic-Triggered Cancellation for Nonpayment (using AtlasMD)

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

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

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

Determining the remaining balance & ending the membership:

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

Assigning all files & messages:

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

Archiving the patient:

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

Adding to the Master Status Report

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

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

Self-employment tax

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

Home office

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

Clothing

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

Meals

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

Health insurance

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

Cars

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

Travel

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

Event/party at your house

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

Interest

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

Transfer of, normally, personal expenses to the business

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