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.

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