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.

There are several EMRs to choose from now, many geared specifically for DPC practices.

Below are some general questions to get you started in choosing the EMR that's the best fit for you.

Be sure to ask for a demo and also references of current users and recent users who terminated.

EMR SUPPORT

• Is support response available within 24 hours?
• Is the company open to suggestions to improve the EMR?
• Is customization allowed?
• Are auto-updates available, and without fees?
• Is it HIPAA-compliant?
• What happens when you want to switch to a different EMR, and costs?

EMR PLATFORM

• Is it compatible on iOS/ Android / Windows / Chrome/ other platforms?
• Is it viewable and fully functional on mobile devices (phones/ tablets)?
• Is it cloud-based?<//li>
• Is it paperless capable? i.e. forms can be filled out online
• Can data be easily uploaded to a local storage source (in-house server / hard-drive)?

COSTS

• What is the set-up fee?
• Is there a trial period?
• Is there a contract term?
• What is the cost per user or per patient panel? If cost is based on patient panel size, are inactive patients' charts counted in the patient panel?
• Is there a cost to maintain inactive patients' chart (for the required 7 years)?
• Which features are built-in and included, and which features integrated with separate vendors and are added costs?

INTEGRATIONS

EMRs may have extra costs for these features here, or may integrate with other companies to provide these services:

PHONE NUMER

• Is a separate business phone number provided?
• Is there an added cost for the phone number?

TEXT/MESSAGING/PORTAL

• Are texts/emails/calls imported or uploaded to patients' charts?
• Is there a patient portal for secure messaging?

WEBSITE

• Does it integrate with your practice website for patient self-scheduling?

FAXING

• Can you send and receive faxes?
• Can you edit faxes within the EMR?
• Is there an added cost or a limit to how many pages can be faxed?

LAB INTEGRATIONS

• Are lab interfaces uni-directional or bi-directional?
• Can your order labs for self-pay as well as insurance?

MARKETING

• Does the EMR support mass e-mail or integrate with a mass email service (ie Mailchimp or Active Campaign)?

Which other vendors are integrated?

PHYSICIAN FACTORS:

• Does the layout of the patient chart fit your style (i.e. having everything on one page vs. having only the active screen on the page)?
• Is it customizable?
• How easy is it to search? Is search based on patient criteria or within patient notes?
• Is there a built-in telemedicine platform?
• Can you message/email/text patients from within the EMR?
• Can you schedule a future message/email/text to patient?
• Can you track patient results & referrals?

CHARTING

• Are there templates, macros, short-cuts, right-click menus or hot keys?
• Is free-text allowed?
• Is there a lot of clicking or typing required?
• Is it better for large/detailed notes or small/simple notes?
• Can you import images? Can you draw on them are you import?
• Can vitals and labs be graphed?
• Can you set patients' preferred pharmacies, specialists, facilities, etc?
• Does it support dictation?
• Can you unsign/amend notes?
• Can you delete documents?
• Can you easily reassign documents to other patients (ie if you accidentally assign it to the wrong patient how easy is it to more)?
• Are there custom workflows in notes (i.e. if ICD codes are required)?
• Are pediatric growth charts integrated and appropriate?

PRESCRIBING

• Are medication databases updated regularly?
• Is e-prescribing available?
• Is e-prescribing available for controlled meds PDMP?
• Is there an added cost to e-prescribing?
• Can you add compounded medications?
• Are supplements fully integrated like prescriptions?
• Is there a medication interactions feature?
• What is the appearance of the medication list?
• If you're dispensing meds, is inventory management integrated?
• Are alternative and complimentary treatments in the database?

PATIENT FACTORS:

• Encouraging patients to use their patient portals allow patients to schedule appointments, ask for refills, and send secure messages.
• Is there a patient portal and is the patient portal user-friendly?
• Does the patient portal allow self-scheduling, refill requests, document retrieval & uploads, and secure messaging?
• Are patients able to sign forms online (ie patient agreement, surgical consent, etc)?
• Can patients upload documents and pictures?
• Can patients view appointment summaries?
• Can patients enter their own credit card number, pay bills, etc?
• Can appointment reminders be texted?

BUSINESS FACTORS: (practice management)

BILLING

• Does it include a billing software? If not what billing software does it integrate with?
• Does it include a membership subscription & billing manager?
• Can you assign different charges for different groups of patients?
• Can you adjust charges at the time of billing or when necessary?
• How easy is it to add a one-time charge (like labs/medications)?
• Can you create a superbill?
• Can you easily print a claim form for patient to submit to insurance?
• Can you easily print an invoice for patient to submit to employer?

INVENTORY

• Does it have built-in inventory management for medications and supplements?
• Is there an RX label generator for dispensing?

TEAM & TASK MANAGEMENT

• Can you assign tasks and reminders to different staff?
• Do tasks have to be linked to a patient, or is there a way to send non-linked generic office tasks?

POPULATION MANAGEMENT

• Can you extract population data?
• Is there automatic notifications of screenings or population needs?
• Can you upload any handouts you'd like?

Nothing solidifies a patient’s commitment to your services than saving them money, and imaging is one of the areas most ripe for cost savings. It’s also a lot of fun to realize that there are deals out there that you were likely never aware of when you were part of the “system”. Most patients assume that using insurance is the best way to obtain the best deal and save the most money. With the insurance based pricing structure, high deductibles, and coinsurance, in the vast majority of cases, nothing could be further from the truth.

The level of imaging utilization and run away pricing in the U.S. healthcare network wastes hundreds of billions of dollars per year (If the U.S. did less imaging, fewer numbers of the 25 most common procedures, and lowered prices and the number of procedures to levels in the Netherlands, it would translate into a savings of $137 billion.) (Source)

The average cost of a CT exam in the U.S. was $896 per scan as compared to $97 in Canada, $279 in the Netherlands, and $500 in Australia. Additionally, the average cost for an MRI in the U.S. was $1,145 compared with $350 in Australia and $461 in the Netherlands. (Source)

With such large profits at stake for the system, how in the world can we work effectively on our patients’ behalf to save them money and negotiate fair pricing? While the facilities available will vary regionally, a few fairly simple principles apply nationwide.

AVOID HOSPITAL BASED IMAGING! - Results show that average hospital prices range from 70 percent higher to 208 percent higher (nuclear medicine) than the average prices at free-standing imaging centers. (Source)

UTILIZE FREE-STANDING IMAGING CENTERS - The pricing at free-standing imaging centers will be significantly lower for patients whether they choose to pay cash or have the charges submitted to insurance. It is worth having a discussion with the centers near you to obtain a list of their cash prices. At times, they will offer additional discounts for client bill pricing in which the imaging center bills your clinic for the imaging, and you then collect fees from the patient. Whether the benefit to patients is great enough to warrant the additional financial risk and administrative burden to your clinic will vary from practice to practice.

ENCOURAGE USE OF CASH-ONLY IMAGING COMPANIES - Similar to the growth in the DPC arena, over the past decade, several of our radiology colleagues have discovered the freedom of refusing to deal with insurance. Cristin Dickerson, MD founded Green Imaging in 2011 and has grown the company to a nationwide presence. Similarly, RadiologyAssist was started as a way for the uninsured population to obtain imaging at discounted cash prices but is available to anyone who chooses to pay cash rather than file their insurance. Rather than building their own imaging centers, these companies purchase unused capacity at existing imaging centers at a discount and pass that savings along to the patient. The caveat with these cash-only companies is that patients must pre-pay for their services prior to scheduling, however they can utilize Care Credit or a layaway type plan in many cases if paying the entire cost is still a challenge even at the discounted rate. At Radiology Assist the price for plain films starts at $33 and MRI as low as $265. These networks are expanding rapidly but as of now, they are not available in the far northern states including the Dakotas, Nebraska, Wyoming, Montana, and Idaho. Ordering imaging through these companies is simple and can be done online or by uploading a referral form.

https://greenimaging.net/

https://radiologyassist.com/

Written by Kelsey Smith, MD

Any venture worth doing is worth doing with someone else. As you are building your business vision and laying out a plan for your start-up, ask yourself: who is your business team?

DOMESTIC PARTNER

When considering DPC, physicians with a domestic partner should involve their partner in the decision to switch. Working together to realize your dreams can bring you closer or apart, depending on how invested your partner is in your DPC dream. Whether you have a partner who can hold down the fort at home, provide income and health insurance, offer design/graphic device, help with keeping the books, do the billing, run your office or just enjoy dinners while you ramble on about all of your ideas and needs, a supportive partner is a critical component to business success.

LOCAL INDEPENDENT PHYSICIANS

Seek out like-minded entrepreneurial independent physicians of all specialties. Most are intrigued by the Direct Primary Care model and are eager to work with our cash-paying patients as less billing means less overhead. You may develop a local network of supportive specialists, not only with patient care but also with physician entrepreneurship, which can sustain you through difficult or lonely times.

LOCAL BUSINESS NETWORKING GROUPS

There are business networking groups that can be very helpful in introducing you and your business to your local business community. Be prepared to join as a member and go to meetings and events to network with other small business owners. Be aware that networking takes TIME and many conversations but eventually as you and your DPC model become well known and trusted, you will begin to get referrals.

• “BNI”- Business Networking International.
• Chamber of Commerce/Local Business Associations
• Faith community (if that applies to you) Consider offering to give presentations on medical topics (not DPC) to increase exposure in your community
• One Million Cups
• Meetup.com (look for entrepreneurial groups)
• Civic groups like Rotary International and Lions Clubs can all help you establish connections and useful business relationships. They may not bring in a substantial number of patients but they will help with your business acumen and word of mouth knowledge in your community.

Other members of your team worth considering include:

• Accountant
• Lawyer
• Business mentor. Use your business networking meetings to learn tips for running a business from other entrepreneurs.

LOCAL AND NATIONAL DPC PHYSICIANS

Call or email your local established DPC physicians. Most will be happy to hear from you and help you along the way. Some are less interested in being part of a wider DPC community - don’t take it personally! The national DPC community is full of physicians willing to help you get off the ground. Check out the DPC Alliance member directory, send an email, and ask for help. See How to Find Your DPC Mentor for suggestions.

Steps toward financial stability include:

1. Getting a firm hold on your personal/home finances. (See Financial Consideration)
2. Write a business plan with financial projections. A guide to help with your business plan is available from the Small Business Administration. You may also find some free in-person help through a Small Business Development Center at your local college or university. (See Writing a Business Plan).
3. Important elements for initial financial projections include:
   • Determine your pricing. Many variables go into this. (See Setting Membership Pricing).
   • Anticipate and budget for one-time expenses needed to open.
   • Plan for and budget your ongoing business expenses.
4. Choose your accounting software. Check out Xero.com and Quickbooks.intuit.com.
5. Find an accountant with small business expertise to help you transition from being an employee to a small business owner (which comes with the responsibility of properly tracking expenses, managing write-offs, utilizing the business to pay for business-related expenses, and tracking owner contributions and owner distributions -- among others).

We’ve all seen that patient. The one who has tried EVERYTHING for migraines and nothing works. They had too many side effects on triptans, topamax, verapamil, or propranolol. Acupuncture, massage, oxygen, and cryohelmets were not effective. You may know there are some injections that can be done, but perhaps your patient doesn’t have insurance and can’t afford to see a neurologist.

Prior to referring your patient out, you may be able to try some of these injections in the office.

First and foremost, it’s important to find out if there are any specific triggers for the patient’s headaches. Some people find that stress and tension seem to cause neck pain and trigger migraines. For these people, you can start by trying simple trigger point injections into the cervical paraspinal muscles once every few weeks until their headaches diminish. You can use 0.5-1 cc of 1% plain lidocaine in the points of maximal tenderness, but some like to use a little steroid, such as Kenalog, as well.

If you want to go even further you can do a simple occipital nerve block procedure which involves injecting lidocaine over the occipital nerve to block pain.

Here is a great video on how to do this procedure.

In combination with cervical trigger point injections, occipital nerve blocks work very well for migraines associated with cervical muscle spasms. Some patients respond well even if they don’t have associated neck tension, so it is worth trying if their migraines are intractable.

Three other nerve blocks may be helpful for more traditional migraines or frontal headaches. These are the supraorbital nerve block, supratrochlear nerve block, and sphenopalatine nerve block.

The supraorbital and supratrochlear blocks are generally done together. The supraorbital block is easiest and sometimes useful on its own. For this block, you inject about 1 to 1.5 cc of 1% lidocaine just over the supraorbital notch.

The following video is a great overview of these injections for migraines. This surgeon also does a trigeminal nerve block, which may also be useful but not as common.

On a side note, keep in mind you can do a simple supraorbital block for forehead lacerations.

Here is a video example of this. 

Lastly, you can try a sphenopalatine block. There are many ways to do this block.

The easiest (but also the most expensive) way to do this is to use a special catheter.

There are 3 devices: Sphenocath ($670.50 for a 10 pack), the Allevio ($625.00 for a 5 pack), and the TX360 used in the MiRx protocol ($650.00 for a 10 pack). The nice thing about these catheters is that you can access more precisely the correct spot over top of the ganglion every time. When setting your price, be sure to cover the cost of the catheter, lidocaine, and a small markup for credit card processing. Dr. Blackwell at Clarity Direct charges $90 per SPG block, which patients are happy to pay as they typically experience about 6 weeks of relief. Although not ideal, catheters may be reused up to 4 times before they stop working. Dr. Blackwell does not charge for blocks when a catheter is reused. Make sure to clean it well by soaking it in alcohol after use and clean it before keeping it in the original box for the next use.

Here is a video of Dr. Kissi Blackwell, a DPC Alliance member demonstrating. 

You can also use a very inexpensive angiocath on the tip of a syringe, but you can potentially miss the spot since they are not very long, but they are much less expensive than the special catheters and worth a try.

Here is a video showing an ER doctor doing this for acute migraines. He states in the video they last just a few days and he does them weekly or biweekly for patients, which possibly means that this technique is not quite as good at reaching the ganglion as those who have had blocks using the procedure-specific catheters typically report 6 weeks of relief or more.

If you would like to learn a little more, this is a really nice overview of the sphenopalatine block and the premise behind it linked here.

* All videos linked in this article are provided solely as an educational reference for DPC Alliance members.

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.

For various reasons, over the past several years family physicians have seen their scope of practice dwindle. One such reason is lack of time in their schedule to practice Inpatient or Obstetric medicine. Direct Primary Care allows physicians plenty of time to re-capture a more full-spectrum practice. Many DPC docs take their continuity to the next level by taking care of their patients in the hospital, who can still bill insurance for facility fees (just not professional fees). Many DPC docs deliver babies for a set “global” cash fee, some even practice operative obstetrics.

Reasons many resume inpatient care:

• Value: your patients get more for their money, which helps with recruitment and retention
• DPC docs know their patient better than the hospitalist
• Increases coordination of care and continuity to the outpatient setting
• Doing social rounds? Why not just manage the patient? (Your patients will be texting/calling you from the hospital anyway!)

Barriers to resuming inpatient care:

• Hospital Privileges
  • Easiest to maintain current privileges or obtain out of residency harder to get back
  • May require board certification
  • Occasional turf battles
  • Administrators who don’t understand Medicare Opt-In/Out
  • May require the attendance of Med-Staff meetings, EMR training use, peer review meetings
• Malpractice Insurance may go up
• Some hospitals only give privileges to their own employees (University hospitals, for instance)

Additional barriers to resuming obstetrical care:

• Many have lost the skills after a prolonged absence from OB, could need to be proctored back, refresher courses, ALSO and NRP training, etc.
• Malpractice insurance may go up high enough it wouldn’t offset money made from doing OB, depending on circumstances such as OB numbers, state of practice and OB malpractice rates, etc.

As with many ways of increasing the scope of practice, using social media and the DPCA membership to identify a mentor with experience is invaluable in achieving these goals.