DPCA Articles

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

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

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

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

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

Obtaining a contract for your desired labs and prices:

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

Phlebotomy options

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

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

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

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

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

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

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

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

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

Networking to find local direct-pay resources

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

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

Direct Specialty Care

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

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

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

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

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

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

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

Benefits of SEO 

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

1. Start with Your Practice Site and Site Content

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

Some general SEO tips for every website:

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

2. Claim Your Google Maps Business Profile

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

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

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

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

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

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

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

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

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

https://youtu.be/9GoZPukjqrg

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

OVER-USERS

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

OVER-SETTING BOUNDARIES

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

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

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

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

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

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

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

Things to decide:

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

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

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

Keeping your Schedule Open

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

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

Price transparency and direct-pay websites

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

There are a few types of websites in this realm.

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

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

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

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

Online booking platforms with real pricing & sometimes scheduling.

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

START UP LETTER/SIMPLE FORMS

First Office Transition Letter

Second Office Transition Letter

Credit Card/ACH Authorization Form

Record Release Form

First Missed Payment Notice

Second Missed Payment Notice

Letter to Confirm Membership Cancellation

Communication Guidelines for Patients - Micropractice

Communication Guidelines for Patients - Office with Staff

ADVANCED PRACTICE FORMS

Staff On-Boarding Checklist

Staff Off-Boarding Checklist

Employee Termination Letter

Photo Release Form

Procedure Consent Form

SAMPLE AGREEMENT FORMS

Patient Agreement

Medicare Opt Out Patient Agreement

Staff Contract

Provider Contract

Compensation Amendment

Employer Agreement

Non-disclosure/Non-Solicitation Agreement

Membership Termination Letter

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

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

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

The potential benefits of running a hybrid practice include:

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

The potential disadvantages of running a hybrid practice include:

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

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

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

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

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

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

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

Here are some upsides and advantages to working with employers:

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

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

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

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

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

Learn about the Cons of Working with Employers.

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

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

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

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

PATIENTS COMPLETING FORMS:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So how do you get started?? 

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

POCUS Courses: 

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

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

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

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

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

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

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

You should strive for a name that is:

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

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

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