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).

Many topics affect DPC as a model, you as a physician, and your patients. This list is ever-changing of course, and depending on the political climate, certain issues are of more importance than others. Following specific issues depends on an individual’s time, energy or passion. However, don’t forget the importance of grassroots advocacy, and know that physicians can play a big role in advancing these issues if you are inclined. The DPC Alliance does not participate in supporting or opposing specific legislation. 

Here is a brief list of issues that are pertinent to our model that have come up over the past few yea

• HSAs/HFAs
• The state insurance board
• In-office medication dispensing
• Business taxes (specifically for professionals)
• Threat of liability lawsuits
• Scope of practice expansion (NP/PA and practice rights)
• EMR mandates
• Mandates for accepting insurance or other payers (ie., Medicaid/Medicare)
• Regulations regarding pharma and medication pricing
• Regulations regarding health insurance requirements for individuals

One DPC resource that has a wealth of knowledge regarding healthcare policy issues is DPCfrontier.com. This is an independent DPC physician-owned website and is a great resource for new and old DPC physicians alike.

Working with employers can lead to some legal concerns that are best handled with plenty of research and lead time, if possible. These issues, especially if employers are large (50+ employees) or offering health insurance, can be complex; varying from state to state.

With many employers, there is no simple way to hash out all these legal issues without the help of a lawyer well versed in employer plans and DPC.

Many mid to large-sized employers will be using self-funded plans, and there are legal requirements for those to protect employees -- like ERISA (Employee Retirement Income Security Act of 1974). ERISA is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. There are specific rules to follow here for employers and for brokers/advisors which may also involve you, the DPC physician. So, the employer will need legal help to be sure they are following the rules and you will need help to be sure your contracts with the employer are correct.

You need to have a DPC knowledgeable lawyer to help you here. Contact the DPC Alliance if you would like help finding one.

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

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

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

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

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

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

Review this article on terminating insurance contracts.

Abscess incision and drainage is a very simple procedure that should be in every primary care physician’s arsenal.

Most textbooks such as Pfenninger and Fowler’s Procedures for Primary Care teach this skill.

Historically, I&D was performed by cleaning the skin of an abscess with betadine, puncturing the skin with a #11 scalpel blade, evacuating/cleaning the cavity (including breaking down the loculations), and then packing the wound with strip gauze (if you’re not familiar with strip gauze, it looks like a long shoestring made of gauze). The packing would be (painfully) removed and replaced every 2 days until the wound had granulated in.

In more recent years, an I&D technique known as “vessel loop drainage” has emerged that is widely considered the superior treatment option. This technique uses drainage but no packing, which eliminates the need for repetitive and painful packing replacement. (Alliteration intended.) This technique has superior healing times, infection rates, less scarring, and higher patient satisfaction. A video demonstrating this technique is linked below.

The physician only needs betadine, saline, a #11 scalpel, a silicone vessel loop, a curved hemostat, a cotton-tipped applicator, and gauze sponges to perform this procedure. These supplies cost less than $4 total.

https://vimeo.com/19580472

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

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

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

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

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

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

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

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

Resources for Finding a Mentor

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

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

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

Social Media:

DPC Alliance Facebook Group

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

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

DPC Conferences:

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

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

Questions:

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

Being an advocate does require a small amount of effort - or a large amount. It all depends on what you are able to do. At the smallest level, you can participate in a letter-writing campaign which is typically started by an organization. The organization will email you a link that requires you to insert your name and contact information then e-sign a pre-written form letter to your legislators (state or federal). These campaigns generally take a minute or two from start to finish, so can be a great way to be an advocate when your time is limited. Helpful tip: you can modify the form letter to include a story from you or your patients to make it more meaningful to your legislator, just keep it brief and HIPAA compliant.

If you’re ready to take it a step further but not quite ready for a one-on-one in-person visit, many medical organizations organize Lobby Days. Typically at a Lobby Day, the organization will help schedule meetings with legislative staff on your behalf and you will meet the staff with a few other physicians. This will enable you to practice meeting with legislative staff members without the stress or workload of setting up private meetings. If this is something of interest to you, you can reach out to your local or state medical organizations to see when their next Lobby Day will be.

However, if you are ready to schedule your own one-on-one meetings, they can be very effective. To learn more about how to contact your legislators please see How to Contact Your Legislator. If you are unsure who your representatives are, you can find them online at USA.gov. When requesting an in-person meeting you can offer to meet them at their office, or invite them to your clinic. Make sure you prepare for the meeting as they have very busy schedules. To get the most out of your visit, a few suggestions include:

• Treat all staff members courteously, as you would expect done at your office.
• Address the legislator professionally (Mayor Doe, Representative Doe, etc).
• Introduce yourself with your credentials – tell them you’re a doctor and where you practice, etc.
• Know the bill number and title and their position on the bill
  • If they are an author/co-sponsor and you are in favor of the bill thank them for their support. If you are mostly in favor but would like to see some changes, thank them for their support then explain why your changes are important.
• Bring with you a brief bulleted handout on the topics you are discussing so they can take notes and take it back to refer to later.
• Use your own words to tell your story and how this will affect your profession and your patients. Your stance should align with their constituents – who are electing them.
• Don’t take notes while meeting with them. Take notes after you leave before you forget what was discussed, but during the meeting maintain eye contact and focus on them. Also, do not ask if it is ok to record the session - it is never ok to record the session (though they may ask to and it is up to you if you wish to allow it).
• Follow-up with a thank you email and answer any questions you did not know the answer to.

An elevator pitch is a brief description of your practice that explains what you do, how you do it, and why the listener should be interested. Crafting a good or a couple good elevator pitches is crucial as many doctors, especially the more passionate ones, will tend to overshare and end up causing the other person to lose interest. 

The key to the elevator pitch is not to include everything, but rather include enough to act as a “teaser” enticing the listener to ask, “Tell me more...” You can explain what you do on a very broad scale and consider including a sentence about what sets you apart from your competition. If possible, personal examples help better engage your listener.

It may be worth having more than one elevator pitch for specific audiences. For example, the “pitch” for businesses vs the “pitch” to someone suffering from chronic diseases vs the “pitch” to an otherwise healthy family interested in continuity of care and accessibility.

An elevator pitch does not need to be a “sales pitch”. In fact, it ought not to be. It should simply provoke enough interest that the listener wants to know more.

Examples for consideration:

“[Business name] is a Direct Primary Care office which means we provide routine medical care to our patients for a set monthly fee. Our prices are upfront and transparent. In a typical medical office, you may not see your bill for 6-18 months, and you will likely be surprised by how expensive it is. Our patients know exactly how much their care will be before they leave the office so they don’t have to worry about how they’re going to afford to go to the doctor.”

“[Business name] is a different type of medical practice where we work directly with our patients instead of their insurance company. This enables us to provide better care and greater access for less money. The last time you were sick were you able to see your doctor, or did you have to go to Urgent Care? Not only can our patients see their doctor the same day, but they can also text or email their doctor directly with questions or concerns.”

“[Business name] does primary care a little different. We limit the number of patients we take care of so that our patients get more time with their doctor and better, more personalized care. This means that all of your children can do their wellness visits at the same time, within a week, as opposed to either waiting 3 months or only seeing one child at a time due to overbooked schedules. Your whole family can get their medical concerns are taken care of at once, which means fewer trips back and forth for you.”

If you want to work with employers, start in your own office! Your patients likely work for someone or own a business. Start there. Can you offer services to their employer?

Next, start looking around your community where employers and entrepreneurs meet. The Chamber of Commerce is a good start. Civic clubs like Rotary, Lions Clubs, or the like frequently need speakers; you could provide significant insight into health care topics -- especially DPC. Church and community groups (your neighborhood development association, the YMCA, etc.) that frequently do health fairs or benefits to raise awareness of certain issues are also great resources. Jump right in there and spread some DPC love.

Other good connections can be made at local business groups like BNI (Business Network International), 1 Million Cups, or LEAD groups. These meetups -- and others! -- connect entrepreneurs looking to grow their businesses. Check these and others out in your community to see if they can work for you.

Finally, social media. You need to have a presence on social media to reach employers using Facebook, Twitter, Instagram, and LinkedIn. Most employers are there on social media and making a name for your DPC practice with frequent posts can get you connected.

One last note, there are benefits advisors are looking to connect employers and DPC -- read about that here.

There are many ways to contact your legislator. Email, phone, or in-person are some of the most frequently utilized. Most legislators have a “contact us” option on their website, and the state and federal government sites have “contact your legislator” forms which are great for sending emails. Old-fashioned letter writing is also an option but generally not recommended as these go through thorough safety screenings before reaching the legislator and their staff. Meaning they will take a long time to arrive. Regardless of which method you choose, here are a few tips for effective communication.

• Read through their website and see if they already have a stance on the issue you want to speak to them about - or if they’ve supported any relevant policy previously.
• If you are calling a state or federal legislator, ask to speak to their health policy advisor/liaison. They are an important part of the communication process because they are who follows the healthcare policy for the politician. You’ll want them to be abreast of your concerns and will often be involved with the meeting with your legislator and taking notes.
• If you are sending an email, make sure the subject clearly states what issue you are writing about to help their staff route it to the correct person. For instance, if you are writing to ask for their support for a specific bill the subject line should read “Please support HB/SB XXX”.
• Be short and to the point. They get communication requests from many people every day and have very limited time to devote to you so do not waste it on unnecessary small talk.
  • Introduce yourself. Being a physician carries more weight with legislators than you may realize, and if they know that a physician is contacting them about healthcare-related concerns they will devote a little more energy to you. Even if you have emailed them or called them before, they will not remember who you are or that you are a physician, so reintroduce yourself every time until they make it clear they know who you are.
  • Explain why you are contacting them, why it matters to you, and why it matters to their constituents. You may be contacting them about a general issue and there is no current policy. You also may be asking them to write legislation (if you can bring a suggested draft that’s perfect) or co-sponsor already existing legislation.
• If you are sending an email, only discuss one issue per email (and do not send multiple emails back to back - you do not want to overwhelm them).
• Always leave your contact info. Whether it’s a business card or handwritten or the signature of your standard email. Include phone numbers, emails, and your clinic information.
• Offer yourself to the legislator as a resource they can use on health industry issues.
• Get contact info for whom you spoke with and follow up with them.
• If you speak over the phone or in person, make sure you send a thank you email and recap what was discussed.
• As your relationship with your legislators and their staff is growing, treat them like you would your favorite patient/relative. Answer their calls or return them ASAP. Kindness and support will go a long way to enhancing the relationship and increasing your influence.

Before meeting with an employer, develop your fee schedule for employers. You can use your current fee schedule -- which some DPC docs prefer -- or you can adjust it. For example, some practices revert to a single fee for any enrolled patient. This single fee for employer-based adults is usually an average of adult fee ranges you offer.

Once you have your fees set, you need a plan to get your money. Like the individual patient agreement, the employer DPC agreement should spell out the fees and how the fees will be paid. Most DPC clinics use ACH to directly draft employer payments right from their bank account once a month. This makes payment simple and inexpensive. You can certainly have employers pay you using other formats like debit card or credit card but ACH is the most cost-effective way.

You should set a payment date and invoice on the first of every month. You can allow the employer to set the payment date, but it is much easier to set one date for all employers (i.e. all payments occur on the 10th of the month). This helps keep all ACHs from employers at the same time. Be sure to share this plan openly with the employer so they understand how the process works.

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

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

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

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

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

The short answer is, “It depends.”

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

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

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

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

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

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

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

Few will argue that primary care has changed as corporate fee-for-service practices and their payment systems evolved. The average length of a family physician appointment is currently about 8 minutes. It is common for primary care physicians to see over 20, or even 30 patients per day. Many will argue as to the quantity vs quality issues that this change has caused, but one thing is very clear: patients prefer to have more time with their physicians and physicians feel rushed and regularly feel that their job satisfaction, as well as perceived quality of care provided, is worse. And most primary care physicians now have 2,000 patients or more.

In Direct Primary Care, this paradigm has changed. It is not uncommon for DPC physicians to schedule all or mostly one-hour visits, and even make 1-hour appointments available on a same or next day basis. Also, DPC physicians generally have smaller patient panels (on the order of 500-600.) Thus, the main thing that has changed is the number of patients a physician cares for and the amount of time spent with them.

With time, a DPC physician can expect to see a practice that differs in the following ways from a practice inside the traditional FFS system:

Deeper, more intimate, and meaningful relationships

Time to dig into and research difficult medical cases, and thus provide a wider spectrum of care and make fewer costly, inconvenient specialty referrals

Time to do more procedures that were formerly referred in the interest of clinic efficiency

Wider spectrum of care due to more time available to give patients (for instance, a family doctor may provide more mental health support and rely less on counselors or psych referrals)

Time to do more thorough patient examinations and education

Time to develop and devote to alternative methods of patient care (phone, e-mail, text, video calls internet education articles, etc.)

Time to devote to continuing education to expand your scope of practice more fully to provide better value

This list of highlights (and many more) are why so many DPC doctors love their jobs!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One place where primary care physicians commonly feel unprepared for is fracture management. However, many routine fractures are easily and safely treated by the PCP, and at substantial savings to the patient. Increasing your comfort with basic fracture management is an easy way to greatly increase the value you offer your patients.

Step One, Resources:

The first resource most family physicians recommend is the book Fracture Management in Primary Care by Eiff and Hatch. This is an invaluable resource, because it not only does a great job of reviewing all common fractures, dislocations, etc, but it helps the physician decide when the injury is appropriate to treat in the PCP environment, and when a referral is indicated. When PCP treatment is indicated, the book details the proper treatment, follow-up frequency, imaging frequency, etc. The second important resource is a good referral base. It is advantageous to have a local/regional orthopedist with whom you are on a first-name basis and have on speed dial. In a tough ortho case, it’s easy to snap a pic of the x-ray, text it to Ortho and ask for advice.

Step Two, Education:

If you need refreshers, go to an ortho refresher/casting/splinting workshop, etc. Or again, befriend an ortho and spend a couple of days in their clinic and have them teach you some stuff. Be creative. Ultimately, the physician will need to get out of his or her comfort zone to some extent if they’re not comfortable with ortho, and soon it won’t be scary.

Step Three: Equipment:

You’ll need casting, splinting, and bracing equipment. There are lots of options here, some are just physician preference. Here is a brief summary of equipment worth having:

• Casting material
  • Fiberglass cast rolls (generally 2”, 4” and 6” widths) (Some docs like OsteoFX roll-on casting material--handy but more expensive)
  • Cotton roll cast padding (alternative option: Waterproof cast padding-more expensive but often very handy)
  • Stockinette (also some various sizes)
• Splinting material
  • Padding/splinting combined pre-made splint products: OrthoGlass vs Plaster/foam
  • ACE bandages (2”, 4” 6”)
• Finger traps (for setting very common Colles fractures)
• Arm Slings (S, M, L)
• Cast saw (don’t buy a medical cast saw, you can get a reciprocating “multi-tool” saw and half-round blade from a hardware store--same thing, and more than $1,000 less!)
• Braces (wrist braces, aluminum-foam braces, finger braces, mallet finger brace, etc)

All of the materials mentioned are discussed in books such as Pfennniger and Fowler’s Procedures for Primary Care and there are certainly a lot of different options for casting/splinting materials. As always, it is a great idea to have a mentor who is practicing the skills you wish to develop, which can be arranged with ease in the DPC community through online social media and DPCA mentoring/discussion channels, etc. We all want to help!

If you have meetings set up with employers, how do you know if they are really ready for the power of DPC?

• The first time you meet with an employer, you must assess how serious they are about working with a DPC clinic. Are the decision-makers in the room for the meeting? Who decides on changing insurance and health care plans? Is the business owner or CEO or CFO at the table?
• Some other thoughts to consider.
• Are they looking for a new benefits advisor or willing to change advisors? Many times this is important because the person they have always used is going to want to do things the way they have always done them.
• Are they really considering what is best for employees and not just the bottom line? Finding what the employer’s main motivation is is important. Some will be all about the economics of DPC. Some really do care about their people. Some just want something that will make the employees happier.
• Have they already done their homework about new types of insurance plans? You may want to ask the preliminary question, “What do you know about DPC?” This can give you a starting point for the conversation.
• Is there a top-down approach, i.e. is the CEO or owner onboard or involved? Certainly, sometimes you have to start conversations without these people in the room just to get in the company door. Ultimately these people need to be present because they are the decision-makers.
• What is their time frame? Next open enrollment or in a few years?
• What are their baseline expectations of direct primary care? What should their expectations be for your specific DPC clinic?

Employers that have done their homework and are serious contenders will have well-thought-out answers here. If they aren’t there yet -- be patient. It takes time to turn a huge ship around.

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

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

At the least, you should consider addressing the following:

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

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

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