DPCA Articles

MEDICARE is federally run government healthcare for older Americans. MEDICAID is a state-run healthcare system for low-income individuals. Most MEDICARE patients are those over 65 years old but can also include people on disability (don’t forget about that one).There are 3 main parts of Medicare:

• Part A (traditional hospital coverage),
• Part B (traditional out-patient coverage,
• Part C (private Medicare advanced plans run by private insurance companies like BCBS or Humana), and
• Part D (the drug benefit portion).

This is confusing but the good news is opting out of Medicare means you really won’t have to worry about these issues and your Medicare patients can continue to see you and use their Medicare insurance.This is a common question for us both from patients and physicians, “can DPC docs work with Medicare patients?” Simple answer: 100% yes.Most DPC docs do opt-out of Medicare and when that is done you are still in the Medicare system and retain a PECOS (Patient Enrollment Chain and Ownership System) number which allows you as a physician to order medications, imagining and referrals without any issues from Medicare. Opting out of Medicare does not change your PECOS status at all and nothing changes for your Medicare patients except they pay you directly. You do have to have Medicare patients sign a Medicare agreement with you (see example here). So, DPC works well with Medicare patients as they get more of your time and access as well as use their Medicare for larger medical expenses like insurance should be.MEDICAID rules vary by state and the ability to contract with Medicaid patients will depend on your individual state’s laws. Check out DPC Frontier for more information on Medicaid.

Having a good business plan is essential not only for organizing your thoughts but also if you are trying to secure financing from other sources for start-up costs.

The elements to include:

1. Summary of your business—a snapshot. What is your “Why?” Why will your DPC be the best? Your business success will be directly related to answering this question. Consider reading Sparks Start Fires by Julie Gunther, MD or Start With Why by Simon Sinek.
2. Description of DPC and how it relates to your own business.
3. Market analysis—Research, research! How are DPC practices around you doing? How full are they? How fast was their growth? What are some of their obstacles to success? How much are they able to charge?
4. Services—What you will include in your practice and how will it be advantageous to your practice. (See Choosing Clinical Services)
5. Marketing strategy—Research effective marketing. Most DPC practices build by word of mouth and boots on the ground. Keep marketing expenses to a minimum. Ask your mentor (See How to Find Your DPC Mentor
6. Funding request—How much money do you need for your plan? Hopefully, starting out, this number is very very low. Start with the lowest start-up costs possible (See Financial Considerations)
7. Financial projections—Calculate estimate based on membership rates, projected growth and retention rate, and overhead costs.

Explain why you care about DPC and your patients, the positive impact on the community, and how your passion will drive your growth and financial estimates.

Don’t forget to reach out to your mentor(s) for advice if needed!

MEDICARE is federally run government healthcare for older Americans. MEDICAID is a state-run healthcare system for low-income individuals. Most MEDICARE patients are those over 65 years old or on dialysis but can also include people on disability (don’t forget about that one).

There are 3 main parts of Medicare: Part A (traditional hospital coverage), Part B (traditional out-patient coverage, Part C (private Medicare advanced plans run by private insurance companies like BCBS or Humana), and Part D (the drug benefit portion). If you establish a relationship with a Medicare beneficiary, you MUST bill Medicare, unless you are opted out. Most DPCs will opt out of Medicare before seeing Medicare patients. This is a tough decision for startup practices who may rely on moonlighting opportunities for income as their practice builds. There are some who decide to do DPC and only bill Medicare. Credentialing your practice with Medicare requires a separate practice NPI and the steps to bill Medicare are outside the scope of this article. Most opted-in practices who bill Medicare will only see patients with traditional part B as you may have to credential with each private insurance company to bill those with Part C Medicare Advantage.

You should also realize that your opt-out is effective for 2 years and will automatically renew every 2 years unless you apply to be reinstated. You have a 90 day window to change your mind, otherwise, assume you are opted-out for 2 years because opting back in within the 2 years is extremely difficult and rarely successful.

Those who opt-out of Medicare (internal link) are still in the Medicare system and retain a PECOS (Patient Enrollment Chain and Ownership System) number which allows you as a physician to order medications, imagining and referrals without any issues from Medicare. Opting out of Medicare does not change your PECOS status at all and nothing changes for your Medicare patients except they pay you directly. You do have to have Medicare patients sign a Medicare agreement with you (see example here) as well as an advanced beneficiary notice (ABN). 

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

MEDICAID rules vary by state and the ability to contract with Medicaid patients will depend on your individual state’s laws..Dr. Phil Eskew’s DPC Frontier has the go-to resource for legal issues on working with Medicaid and Medicare.

What is Direct Primary Care (DPC)?

Direct Primary Care (DPC) is a practice model in which physicians and patients work together directly, without interference from third parties. DPC enables a stronger, healthier, more beneficial doctor-patient relationship.

At this time, most use the definition of DPC put forth by Eskew et al in 2015: “A DPC practice must be a primary care practice that (1) charges a periodic fee for services, (2) does not bill any third parties on a fee-for-service basis, and (3) any per-visit charges are less than the monthly equivalent of the periodic fee.” What, exactly, does that mean for patients and physicians? Let’s examine each of those items separately to get a better idea.

1. Charging a periodic fee: This means that patients pay their physician a recurring fee (monthly, quarterly, or annually) in exchange for healthcare services. People often view this as sort of a membership fee or access fee. Typically this fee covers the majority of care and communication that occurs between the physician and patient. The advantage for the physician is that financial well-being is not predicated on how many patients they can see in a set amount of time. This enables the physician to cover smaller patient panels and provide a more comprehensive service to patients. For the patient, this means increased access to and enhanced care from their physician.
2. Not billing third parties on a fee-for-service basis: This means that when a patient sees the doctor, a bill is not sent to their insurance company. The advantages of this for the physician are no more chasing payments from insurance companies, no more jumping through hoops trying to ensure optimal reimbursement for their work, and no more headaches when insurance companies find excuses to deny coverage. The main advantage of this for the patient is that they will never see an unexpected bill from their insurance for the care their doctor provided.
3. Visit fees are less than the equivalent of the periodic fee: This means that if the physician’s monthly fee is $50, and they also charge a per-visit fee, that per visit fee needs to be less than $50. If any per-visit fee is over the monthly fee, the practice shifts from a DPC arrangement to more of a traditional fee-for-service, where the main income to the practice is from service fees. Most DPC practices do not charge per-visit fees. The advantage to physicians is that monthly billing (and thus bookkeeping) is easier to manage than FFS billing, and eliminates the overhead of office billing staff. For patients, this means a flat, fixed fee will be charged.

One of the benefits of the DPC model for both patients and physicians is the simplicity of the model. Most DPC practices work with local businesses to negotiate cash prices on labs, imaging, counseling, PT, and a host of ancillary services. This improves price transparency and adds benefits to your DPC membership that patients cannot necessarily access on their own. The basic idea here is to add as much value as you reasonably can for your potential members.

Ideas for clinical services to include in your practice model are:

• In-house lab draws (many DPC docs ‘relearn’ phlebotomy, can use MA or nurse)
• Basic in-office tests: flu, strep, covid, EKG, urinalysis, pregnancy, audiometry
• Splinting and casting
• Procedures: laceration repair, biopsies, joint injections, toenail removals, I&D, aesthetics, IUD placement, and removal, etc
• Wound care services/materials
• Nebulizer treatments
• In-house medication dispensary (aka pharmacy) and/or relationship with mail-order pharmacy
• DME: wrist splints, ankle braces, post-op shoes
• OMT (Osteopathic Manipulative Treatment)
• Loaner equipment: wheelchair, knee scooter, crutches, BP cuff
• In house therapeutic phlebotomy
• Cash priced imaging
• Inpatient care
• Obstetrics

Start with a basic list of services and procedures you are comfortable offering, and add more over time as your time, interest and budget allow. Expanding this list is a great way to add value for your patients while growing and learning professionally.

We are so excited you found us.

One mission of the Direct Primary Care Alliance is education. While there are many resources about independent medicine and how to start your own DPC clinic available, it was the hope of the leadership (and membership) of the DPCA at its inception that, over time, the DPCA would evolve to be the resource for all things DPC.

The DPCA Articles were launched in 2019 as one facet of the educational mission of the DPC Alliance and continues to evolve and expand. The DPC Alliance convenes "writer's workshops" intermittently to review, update, and expand the content of the Articles.  If you are a member and are interested in helping, please contact our Executive Director Tiffany Leonard, MD.

The following documents are the result of the work of many physicians (and a few "friends"), who generously gave their mind-share, experience, and time to create this resource.

A big thanks to the following who wrote, edited, contributed and provided content for the University:

• Dr. Staci Benson
• Dr. Kissi Blackwell
• Dr. Lara Briseño Kenney
• Dr. Michael Ciampi
• Mrs. Christine Davenport
• Dr. Jeffrey Davenport
• Dr. Allison Edwards
• Dr. Jack Forbush
• Dr. James Gaor
• Dr. Michael Garrett
• Mr. Joe Grundy
• Dr. Julie Gunther
• Dr. Kirby Farnsworth
• Mrs. Erin Lassey
• Dr. Vance Lassey
• Dr. Tiffany Leonard
• Dr. Marcy Meyer
• Dr. Ryan Neuhofel
• Dr. Shane Purcell
• Dr. Kenneth Qiu
• Dr. Clodagh Ryan
• Dr. Alex Santiago
• Dr. Nathan Seeberger
• Dr. Creighton Shute
• Dr. Kelsey Smith
• Dr. Thanh Taylor
• Dr. Luke Van Kirk

CLICK HERE TO ACCESS THE CHECKLIST

CLICK HERE FOR FAQs

Part One: Introduction and Basic Principles

If you have a wealthy benefactor, a trust fund, or otherwise have money to spend at your leisure, enjoy the ease of your DPC startup, and please feel free to skip this section, and know that the rest of us are jealous, and we expect you to buy our dinner and drinks at the next DPC conference.

We doctors generally have decades of scientific education, but little to no education about business or money. I had ZERO business knowledge, but I knew I had to do DPC so I jumped in, and I learned as I went. The good news is that most of this stuff turns out to be straightforward and common sense.

The first thing to know is that you’re going to have to keep your overhead down if you ever want to make money again. Learn it. Know it. Live it. Keep that overhead down. The profound waste that is a problem inside the system will destroy your DPC.

One good way to keep your overhead down is to avoid interest payments. That means starting up without a loan if you can. This is possible, but rarely so without major sacrifice. But, starting a clinic doesn’t have to cost a fortune, so look at your situation and see if you can make a no-loan startup a reality. Zoom out as far as you can and make some overarching assessments of your financial situation, and your goals. Then, make yourself a few guiding principles and boundaries, follow them as much as possible, and the solution should p assessments, principles, and solution (yours will be different, of course). resent itself.

I’ll demonstrate this by using my own goal,

Goal: Be self-employed ASAP. Pure DPC. Doing medicine right and having time for my patients, family, and self is more important than my income, and when this works, the money will follow, even if it doesn’t, I’m #nevergoingback.

Assessment 1: I owe some money on my house and my 115 acre farm. But not that much. Otherwise, I am almost out of debt, and want to get all the way out.

Assessment 2: I am so dedicated to my DPC goals, that I am willing to make painful sacrifices to achieve them. <<strong>Principle 1: No loans. I hate paying interest, and don’t want to go into debt.

Principle 2: No/Minimal moonlighting. After 9 very long years on the inside, I was due for some much-needed time for my family and my physical and mental health.

Solution: Liquidate.

I sold about ⅔ of the land I’d killed myself working on the inside for 9 years to buy. That was my sacrifice, and it hurt. But, the sting of letting go of it was short lived, and the deep breath of fresh air on the outside of the system instantly made it more than worth it. And, with the profit on the sale, I paid off all my outstanding debt, and put some money in the bank, enough for us to live on for a year or two. We drove old used cars, lived in a tiny house, budgeted tightly, and paid for my clinic’s startup costs, which I kept LOW. And achieved zero debt, which is a good place to be if you’re starting any business.

So that’s how I started a clinic without a loan. But I had equity I could liquidate. The alternative (taking out a loan) is often chosen, sometimes by necessity. This requires income to pay interest on your loan. Assuming you don’t ramp up your clinic overnight, you’re going to find yourself moonlighting all the time to pay for all this, and if your business fails, you’re hosed. I’m not saying there’s anything wrong with this approach, but one of the things that is attractive about DPC is that you no longer work 7 days a week away from your family. If you’re running your new business M-F and moonlighting at nights and on weekends to pay for it while it ramps up, you’re not much better off than you were before. That being said, such pain is temporary, and doing this requires a sacrifice in every case. If that is the sacrifice you must make, then make it. The rough schedule will motivate you to strive all the more to be successful and gain independence in DPC so you can quit the side hustles. There are numerous ways to make money on the side while your DPC clinic ramps up, but that is not the focus of this article.

If you’ve got no choice but to go into debt to start your clinic, you’re still much better off starting the clinic on a very strict budget. It is not difficult to spend hundreds of thousands starting a clinic, and then remain a slave to the bank for years and years to pay it off. Get a line of credit, and use only what you have to, because the smaller the loan, the smaller the payments and the more quickly you’ll be able to pay it off and become a profitable business. Including paying my nurse a full salary for ~6 weeks before we opened, I was able to start my clinic for under $30,000, and I’ve heard of others doing it for even less. I made all that back in a few months and was in the black in no time, with no loan and no moonlighting.

Don’t forget to live on a tight budget. Income is thin for a while during your ramp up. If you don’t want to burn yourself down working multiple side-jobs, it helps to get yourself out of debt ASAP. Sell fancy cars, buy a used car. If you are paying off a mortgage on a big house, sell it and downsize to something you can pay cash for with the money. Clip coupons and don’t shop at Whole Foods. Then you can live in low-stress peace with your weekends off, with 100% of your time available to give to your own business as you build it and ramp up. When you’ve got a successful DPC clinic and have become financially comfortable in a few years, knock yourself out. Delay gratification.

Part 2: Medical Inflation (fake prices in medicine)

In medicine, the cost of everything has become hyperinflated. Stupidly hyperinflated. Fake prices going out and fake prices coming in. Maybe this will get better as a result of our efforts in free-market medicine, but until it does, we have to deal with it. The problem we have in DPC is that the over-pricing in medicine has trickled down to the suppliers and wholesalers, too. If they sell an office chair to a business office, the cost is, say $100. But if it’s medical supply, they take the same chair, label it a nurse’s chair, and list it for $350. But can you blame them? If a clinic is charging patients $125 for a $3 CBC, the “medical furniture” place can justifiably gouge the clinic for an office chair. But if you’re in DPC and you sell that CBC for $3, you need to avoid being gouged, so you won’t be forced to pass these costs on to your patients. Part 3 addresses ways to fight medical inflation and fake prices.

Part 3: Cost-Savings Pearls

1) Get as much free stuff as you can. Free > Cheap.

Of course I’m going to be talking about getting cheap and/or used stuff, but why stop there? Why not go for free stuff? Example: I found a non-profit hospital, and approached the guy in charge of their materials management department. I asked him about surplus stuff--anything they might have--and asked if he would be interested in selling it at low prices to a clinic that was going to be caring for lots of uninsured people, etc. He said that as a non-profit, he couldn’t sell it, but that much of their surplus inventory was going to be thrown away and I could have almost anything I wanted, for free. I got a like-new electric exam table, a power procedure table, an autoclave, numerous cabinets, office chairs, waiting room chairs, paper towel dispensers, glove box holders, a scale, a lab-drawing chair, wall-mounted otoscope/ophthalmoscopes, countertops, curtain track, halogen exam lights, physician’s exam stools and so much more. Buying that stuff new would have cost me thousands and that relationship continues to pay dividends even after 6 years. I send him a huge platter of cookies at Christmas. Who cares if the stuff is used? Clean it up, slap a coat of paint on it where necessary, and admire your not-empty bank account! Later when you’re flush with cash, if some of the used stuff is looking tacky, you’re in a better position to replace it with something nicer (don’t buy new even then–see section 3 below).

This brings to mind another thing: Make your needs known. Talk to your patients, and tell them you’re looking for a ceiling-mounted surgery light. Tell them you’re trying to find another doctor to join your practice. Tell them you wish you were better at painting when they comment on all the paint on your hands. People respect the heck out of you and what you’re doing for the community and want to be a part of it. They will donate time, stuff, money, and labor to you out of the goodness of their heart. When I was painting my new clinic (3,100 square feet–massive job!), one of my patients and his brother showed up with loads of painting equipment, and painted alongside me for 2 days in a row, just to be nice. A homeschooling family of 12 showed up with their 10 kids and did all my landscaping, as a community service project. A patient of mine who knew I was looking for help told a very strong and experienced electrophysiology nurse practitioner that she had encountered in a neighboring city about our model, and that I was looking for help. She gave him my number, and within a week we’d met and shook hands. He became my partner a year later when the new clinic opened, and we are like brothers now. Talk to people.

2) Get free advice and whenever possible, Figure it out.

Don’t forget more than just stuff can be free. Advice can also be free. There are plenty of opportunists who will try to get you to buy services or advice from them, or attend for-profit seminars or boot camps, and they’ll do everything they can to convince you that without their magic small business, marketing, social media, or even DPC knowledge, you’re going to fail. They’ll tell you they can help you build your practice, teach you how to start a business, do your marketing, design your website for you, etc. They’ll even promise you a certain rate of growth, as if they have any control of that! This is all bogus. These services or advice are available elsewhere for free. Just because you’ve never designed a website, marketed a business, set up an internet domain, done the financial books on a business, or whatever it may be doesn’t mean you need to pay some schmuck thousands to do it for you. Figure out how to do it and do it yourself. There are scores of DPC docs out there in numerous online forums, the DPC Alliance, and others, who have gone before you who would gladly give you free advice. Don’t fall for the scams. They’re everywhere--people who want to cash in on your fear and uncertainty, and they’ll grab your energetic leap of faith and suck it dry.

3) Get used stuff, cheap.

This is huge. Don’t buy anything new unless you have no other option. Don’t buy surgical instruments from surgical supply stores, because they gouge you hard. Instead, hit up eBay and Craigslist. I used to use hemoclips in my vasectomies, and the clip appliers from supply places were like $150-200 as I recall. I got a like-new brand-name clip applier on eBay for $10. I got a pristine ConMed Hyfrecator for $350 on eBay, which currently sells for something like $1,000 new. Another option is to find clinics/hospitals that are closing, and contact them about buying used stuff. It’s all surplus to them, and hard to sell much of it, so you can cash in. Call your state medical society and ask about clinics that are closing. Keep your eyes out for auctions and go to as many as you can. I’m not just talking about medical auctions. You can find furniture, cabinets, wire storage shelving, wall art, and much much more. I went to an auction at a hotel that had gone out of business. There, I nabbed a big stainless steel wire storage rack, probably worth at least $250 new, for ONE DOLLAR. At the same auction I got a big UPS worth hundreds (to keep computers on in case of power failure) for FIFTY CENTS, a new mini-fridge for $20 that I keep insulin in, and a break room microwave for $3. I went to an auction of a restaurant that was closing and filled the back of my truck with high-quality toilet paper for $20. I went to a Habitat For Humanity Re-Store (this is like Goodwill but for hardware and building supplies) and found 12 gallons of hand sanitizer gel for maybe $15 (worth $360 today on Amazon). You never know what you’ll find, and you might leave empty-handed, but you can save SO much money if you just look around.

4) Get your hands dirty.

Manual labor is the most expensive thing you’ll buy if you’re building or renovating anything. In my first small clinic location, the materials for the somewhat extensive renovation were approximately $4,000. My Dad and I spent over 720 hours (combined) over about 6 weeks doing all the work ourselves. At the time, that labor would have cost me well over $15,000, and it might have been shoddy work. Lack of experience is a lousy excuse for not doing this. If you can learn to perform surgery on a human being, you can learn to lay bathroom tile, install a sink, or refinish window trim. Watch a YouTube video and learn how to do the work. It’s not hard, and if you’re willing to invest sweat equity, the dividends will be massive.

5) Renting? Negotiate to get paid for your labor!

On top of your labor savings, if you’re renting, you can negotiate the value of your labor against the value of your upcoming rent, since you’re fixing up the owner’s building. In the case of my initial clinic location, the building owner felt that he would be able to rent it for way more after I leave in a couple years (after I completed my dedicated clinic–which I mostly built myself too) because it’s way nicer than it used to be, and that’s worth something to him. We crunched numbers and figured that the value of my labor offsets my rent and utilities for 2 years. So I spent 6 weeks busting my butt fixing up the place, and then I didn't pay a penny of rent or utilities for 2 years. If you’re absolutely unwilling to do manual labor, then barter for it. Find a builder who is getting robbed on his health care, and trade him a year or two of care in exchange for renovating your clinic. And since you’re the one paying him (in medical services) for the work, you can then barter with the landlord for a couple years of rent in exchange for increasing the value and rentability of his or her facility. (See illustration below.) With that smart deal, you get free rent AND free renovation labor. More on bartering coming up.

6) Make your labor a valuable (and free) advertisement.

Another neat thing about doing the work myself, is it gave me a huge selling point on social media, where I did all my own (free) advertising. Occasionally I’d post pictures of myself covered in paint or sheetrock mud, patching up walls or a time lapse video I made of me laying flooring. The tagline on every post went something like “If I don’t have to pay somebody to install this floor, neither do my patients. Welcome to Direct Primary Care.” The patients get that. You’re saving them money. That’s effective marketing, it’s true, and it’s free. Plus, patients like having a doctor who’s a real live human being, and your humility, work ethic, and idealism (you’re doing this to save them money) is a valuable selling point.

7) Bartering.

This one is a little bit tricky, but has its place. When you trade for goods and services, both parties need to feel like they’re getting a good deal. This never works otherwise. Value is in the eye of the beholder. If you can’t both agree that your deal makes sense to you both, switch back to using money. Josh Umbehr once told me “Both parties can agree on the value of a dollar.”

Example: I had a farmer who wanted to trade me about $400 worth of beef for about $1000 worth of membership fees. But my freezer was already full. Obviously, I didn’t like the deal. (Luckily he found out that I could save him over $120 monthly on his meds which more than offset his $100 membership and we didn’t have to keep having the beef negotiation!)

But perhaps you could give a housekeeper free membership in exchange for his or her services. When you take a social history and your new patient tells you he’s a computer/IT specialist at your local bank, ask him if he’d ever be interested in trading a month’s membership fee when you need your computer fixed. Probably will only take him 15 minutes, and saves you a bundle--you both win. Bartering is generally a no-money traded affair, but you’re trading goods or services with a monetary value. For this reason, you need to agree on the monetary value of the traded services and keep records for tax purposes- this is something to discuss with your accountant.

You can also make bartering arrangements with more than one party as mentioned earlier, and demonstrated in the table and illustration below:

HASDOESN'T HAVE/NEEDSDOCTORExcellent Medical Care to GiveRent-free Clinic SpaceLANDLORDBuilding to Rent (in need of remodeling)Time or Money to RemodelBUILDERTime and Skills to RemodelQuality Health Care

8) Ask others.

You’re not the first person to start a DPC clinic on a dime. When you can’t figure out a cheap way to do something, ask somebody who’s been there before you. Join, then reach out to fellow members of the DPC Alliance, use the DPCA’s University database, etc. There are online groups, discussion forums, and books. Many DPC docs have come up with novel ways to save money.

9) Join a GPO.

Group Purchasing Organizations are basically like a discount membership. You pay a fee or buy a product (such as an EMR, for instance) and with it comes discounts at places that sell stuff you might need (medication wholesalers, medical equipment suppliers, wholesale labs/pathology services, etc.). If you can’t get the thing you need anywhere else, and you’re stuck getting it from a supplier, you might as well be part of a GPO so you get a group discount. Along these lines, get Amazon prime. A flat fee gets you free shipping, and often (not always!) you can get things there at lower prices even than your wholesale suppliers, or suppliers in your GPO. Things I sometimes get there include paper towels, business card magnets, certain orthotics/braces, medical supplies for patients (they benefit from my free shipping if they don’t have prime), office supplies, and random odds and ends.

10) Form an informal GPO.

Join up with all the DPC docs in your region. Together you can save each other money by buying in bulk and sharing on things like immunizations, medical supplies, things that expire like suture, meds, etc. Other benefits of this kind of arrangement is selling extra stuff. Maybe toward the end of the flu season, you’ve got 20 extra flu shots that are going to expire on you, but a colleague nearby needs some. You can sell it to them at cost, saving them on shipping and you don’t have to eat the cost of the unused vaccinations. Or trade them some flu shots for some suture or lidocaine, etc. Members of our regional DPC Alliance routinely show up to the quarterly meetings with stuff to trade.

11) Combine several methods listed above.

Here’s an example of how I got a $1300 high-end laptop computer for $700:

1) I bought a deeply discounted open box computer online. This computer did not come with the manufacturer or retailer’s warranty-- a risky purchase if you aren’t a computer guru. As I was worried might happen, the like-new computer had been registered and passworded, etc. by the original owner, so it didn’t work and was locked down like Fort Knox.

2) My patient who works at the bank and is a computer/IT guru traded me 2 months worth of care (a $60 value) and he spent about an hour fully wiping this computer and reinstalling all the software. Now it’s as good as new, and I basically got it for half price.

Starting a DPC clinic doesn’t have to be incredibly expensive, but it is if you’re not willing to be creative, look for deals, find mentors, and negotiate wherever possible. Regardless of how you go about it, do it. DPC is incredibly rewarding!

1. First Steps: Creating a Plan

• Identify and meet with mentor(s)-- successful DPC physicians are great; other entrepreneurs and business owners also give good advice & support.
  • Ask questions. Lots of them
  • How do you want to shape your own practice? As you speak with others, have your own vision in mind. What works for others may not work for you, and that’s ok.
  • Start researching and exploring other DPC practice websites. Get familiar with the basic commonalities.
• Connect with DPC organizations
  • DPCA
  • local/regional organizations of independent DPCs
• Find your resources: guidebooks, startup books, DPC workbooks, etc.
• Attend DPC events
  • DPCA masterminds
  • DPC summit
  • HINT summit
  • D4PC Nuts and Bolts to 2.0
• Write a business plan
  • Mission and Vision statements
  • Timeline to opening (3-18 months depending on lots of factors)
  • Determine the medical services (broadly) you’d like to include in “primary care”
    • Medication dispensing? Allowed in most states, but review your state’s regulation/restrictions here.
  • Decide on features of practice (accessibility, house visits, texting, emails, hours, etc.)
  • Financial plan
    • Calculate total start-up (one-time) costs = $ _
    • Calculate ongoing (operating) expenses = $______________/year
    • There will be lots of unknown expenses that you could not possibly have predicted, so add a nice buffer category of “unknown expenses”
    • Determine desired self-pay (take-home) pay = $ _/year
    • Set membership prices on a cost-basis (tips here)
  • Decide if you’d like to work with employers (sponsored memberships for employees)
    • If so, will need to create unique contracts for employers, employer-sponsored memberships and consider marketing to employers.
  • Get personal financial house in order
    • Secure some side gigs! (i.e. moonlighting options to make income outside of DPC practice while you're ramping up)
      • Tips on jobs if opted out of Medicare
    • Personal/household budget
    • Personal insurances: Life, disability, health
    • Personal retirement accounts

2. Make it Official: Legal Items

• Pick a practice (business) name -- more info on creating a brand below
  • Review this article for considerations on your name
  • Run the options by others: mentor(s) vs. crowdsourcing vs. branding consultant
  • Check name “availability” by Google search, trademark database search, social media platforms, and/or https://www.namecheckr.com
  • Register a trademark? (not absolutely needed, but may be helpful if wanting to protect the name and brand) (Tips here.)
• Set up accounting services
  • Hire accountant and/or bookkeeping course
• Select & learn accounting software (e.g. Quickbooks, Xero, etc)
• Review your state-specific issues that may relate to DPC practice
• Consider attorney(s) if/when needed--may not be needed for many basic matters
  • One for general business matters (help with most issues in business formation)
  • One for issues specific to medical practice (strongly suggest one familiar with helping DPC practices--many will not be familiar)
• Decide on and apply for business structure (LLC, PLLC, S Corp, C Corp)
  • Tips here, ask your accountant/lawyer for personalized advice
• Register business with state agencies (DIY, LegalZoom, or use attorney)
  • Usually this is easy to do on your own. Find your state’s Secretary of State website to register your LLC
• Obtain federal employer tax ID (FEIN) number
• File for DBA (Doing Business As) if needed
• Obtain State employer tax ID number
• Obtain practice (business) NPI (IF you are going to be billing Medicare - may also be beneficial if you opt-out)

3. Financial Basics

• Open business checking account with bank or credit union
• If needed, secure start-up loan and/or line of credit
• Get business credit card
• Obtain retail tax license (only needed in some states, or for some services/items)
• Obtain sales tax license (only needed in some states, or for some services/items)
• Obtain business insurance (aka businessowner's policy). This covers property and general liability; not related to malpractice.
• Obtain personal malpractice insurance policy
• Obtain practice malpractice insurance policy (separate from individual policy)
• Obtain any other insurance your lease or state requires. Such as commercial auto insurance, disability, business interruption insurance.

4. Create Brand and Establish Identity

• Create Logo
  • Use local graphic designer or online design options (99 Designs, Fiverr, Canva, etc)
• Create brand identity/theme: colors (2-3), fonts, etc.— provided by any graphic designer & can be included in logo design
• Purchase domain (web address) name (e.g AcmeHealth.com): Can use Google, GoDaddy, Hover.com other domain registrar, or a website builder service
• Set-up email host (G-Suite makes all below easy, but other options available)
  • Set up personal domain name (e.g. @acmehealth.com)
  • Sign a HIPAA BAA with email host
  • Obtain address for each user needed (e.g. doctorX@acmehealth.com, hello@acmehealth.com, etc.)
• Create website
  • Browse other DPC practice websites to get ideas, ask your favorites who they used/how they did their site
  • Decide if can do DIY with website builder such as SquareSpace, WIX, etc. -or-
  • Hire website design professional (warning: can be quite expensive)
  • Info to contain: bio, services, pricing, FAQs (policies), disclaimers (“not insurance”), clinic location, hours, contact information, social media accounts. By law must include privacy policy.
  • Embed enrollment form or information on how to enroll
• Register with Google “My Business” (hugely helpful for web traffic)
  • Do both your clinic name and your name (you will have 2 google business listings)
• Create social media profiles (not all-inclusive list)
  • Facebook and Instagram (most helpful for marketing and community connections/brand awareness)
  • Twitter (good in some communities, but better for media & policy outreach)
  • Yelp (may help increase search engine optimization)
  • LinkedIn (only good for connecting with potential business partners)
  • Tiktok
  • Others
• Claim online "review" profiles and change practice information

5. Offline marketing plan

• Promotional print materials (local print services, or online options)
  • Business cards
  • Flyers/Brochures/Rack cards
  • Other swag (pens, notebooks, chapstick, hand sanitizer, etc.)
• Send a press release to local/regional news outlets announcing your opening
• Set up meetings/presentations to spread the word (audiences may include churches, Lion’s Club, Rotary Club, various Chambers of Commerce, 1Million Cups, small-business groups, insurance brokers, financial advisors/accountants, realtors, etc.)
• Join business/networking organizations - Chamber of Commerce, Rotary Club, Lion’s Club, AWBA, BNI, church groups
  • Attend networking and business meetings - meet business owners, spread the word, make connections
  • Practice 30 second “elevator pitch” and be prepared to give this at every meeting
• Community involvement
  • Develop relationships with a teaching hospital: teaching students, FM rotation, research, residency, etc.
  • Join the County Medical Society, City Medical Society
  • Join to Chamber of Commerce(s)
  • Visit small businesses and specialists in the area
  • Booth at community events (Farmer’s Market, etc)
  • Local podcasts
• Plan open house/town hall meetings
  • Promote on social media
• Traditional marketing strategies? (Many will not see benefit or good return on this investment--very dependent on your local market)
  • Mailers? Flyers? Local newsletters?
  • Billboards?
  • Newspapers?
  • Yard signs?
  • Radio?

6. Leaving practice or transitioning existing practice to DPC

Employed positions may pose more challenges here

• Review relevant professional and employment contracts for transition
• Notify existing patients: 3 notices (by all methods possible)…
  • 90-180 days out….First announcement letter-- tell the “why”, and broad goals for leaving/switching to a new model of practice (don’t need much details yet)
  • 60-120 days out….Further introduce new DPC practice (more details, website). *** Notify no longer can serve as PCP if not in DPC plan (especially important if transitioning insurance-based practice) ***
  • 30-60 days out….Reminders, share more details of practice (pictures, features, etc.), build excitement for future
• Cancel existing insurance contracts (some require 90 days or more notice) -- tips here
• Opt-out of medicare if desired
  • Submit opt-out form at least 30 days prior to the quarter you want to begin seeing medicare patients

7. Creating a clinic space (if necessary)

• Consider hiring a commercial realtor (can help with many issues below)
• Find physical space for clinic
  • Decide on renting (typically 3-6 month process; longer if major renovations) versus purchasing (typically a minimum of 6-12 months of planning; longer if new construction)
  • Hire contractor (+/- architect if major stuff) if renovations, or DIY if handy
    • Special local building codes for medical practice?
• Register or update new clinic address with all agencies
  • State business registry (typically Secretary of State’s Office)
  • State medical board
  • Malpractice Provider
  • Medical license and DEA
  • County or city agencies
  • Add address to website and social media accounts
  • Add clinic to DPC mapper
• Register with Google “My Business” (hugely helpful for web traffic)
  • Do both your clinic name and your name (you will have 2 google business listings)
  • NOTE: you need a Brick and Mortar address that is accepting USPS mail first, because to verify you they snail mail you a confirmation code
• Obtain business insurance (aka. businessowners policy or BOP). This covers property and general liability; not related to malpractice.

8. Hiring staff & HR issues

• Decide on staff members needed
  • Clinical staff (e.g. RN, LPN, MA, etc); _________________
  • Non-clinical staff? *not always required with small, lean practice
• Obtain payroll services (accountant or online service)
• Obtain workers compensation insurance policy (local insurance broker, or built in payroll service options). See state laws.
• ID Badges (may be required by state)
• Clarify OSHA type requirements
• Post appropriate federal wage and OSHA posters in “workroom”

9. Running the Practice: Legal Items

• Obtain CLIA waiver if doing onsite simple lab testing (e.g. urinary dipstick, rapid strep, etc.)
• Patient Forms: write your own, or borrow from others with permission.
  • Privacy Policy
  • Patient Contract
  • Release of Records
  • Authorization to Discuss PHI (i.e. w spouse, parent, etc)
  • Credit Card Authorization for Recurring Payments
  • If working with employers: Employer Contract
    • Patient contract for employer-sponsored memberships
• Agreement for Controlled Substances (if applicable)
• Consent for Procedures
• CMS waiver (if opting out)
• HIPAA waiver
• Ensure Business Associate Agreement (BAA) in place for any non-employee who has (or could have) access to records.

10. Clinic Office Equipment

• Computer(s): Laptops vs desktops vs tablets (or some combo)
• Printer (laser B+W most efficient option)
• Scanner (w/ double-sided capabilities)
• Label maker(s) for printing medication, lab, & shipping label stickers
• Phones (landline, VOIP phones, or mobile phone)
• Shredder (ideally P4 or higher for HIPAA-complaint shredding)

11. Practice Software and Communications

• Choose patient health records system
  • Paper records? If you want!
  • Electronic: Commonly used EHR options in DPC = Cerbo (formerly MDHQ), Atlas.md, Elation, Practice Fusion
• Choose patient billing service/software that can do recurring billing/payments
  • Commonly used DPC specific options: Hint Health, Atlas.md (also serves as EHR)
  • Other web-based subscription billing platforms (trickier to implement with integrations and HIPAA-compliance)
• Patient communications
  • Allow regular (non-secure) email?
  • Allow regular (non-secure) text messaging (SMS)?
  • Require or offer secure messaging services/apps: Commonly used = Spruce, Hale, Twistle, Twine (some will integrate with EHR & other softwares)
• VOIP phone (voice) services: Good for rerouting calls, and other functions. Some local phone companies will offer this, but lots of internet-based, HIPAA-compliant options, but commonly used HIPAA-compliant are: Ring Central, 8x8, RingRx, Answer Advantage, Grasshopper, Ooma, MightyCall, webfones among others
• Fax service:
  • Traditional (phone-line + machine)
  • HIPAA-compliant web-based options including RingCentral, Interfax.net, UpDox, Faxage, FaxCentral, eFax, etc).
• Other software
  • Pharmacy dispensing software (stand-alone or combined with EMR)
    • MDScripts
    • FlexScanMD
    • Atlas.MD
  • Mail hosting
  • Intraoffice communications
  • Macro/text expanding software
  • AI software
  • PDF Editing software

12. Practice Operations

• Purchase initial clinical supplies (bandages, gauze, syringes, needles, etc.). Will depend on clinical services, but common supply list here, or ask a mentor!
  • For surgical supplies, check eBay and Craigslist- generally surgical equipment is massively marked up from medical supply places, but there is good equipment available affordably on eBay.
• Get basic office supplies (i.e. pens, printer paper, stapler, scissors, etc. etc.)
• Non-legal policy documents developed:
  • Philosophy of care & clinic explainer
  • Employee Health Assessment (for employers who give discount for well checks)
  • Equipment Lease Agreement (for crutches, splints, etc.)
• Create account with wholesale medication/medical equipment supplier (regardless of if you’re dispensing meds or not)
  • Vendor options: Andameds, Henry Schein, McKesson
• If dispensing meds, decide on medication formulary (what you will stock)
  • Make initial order (most practices will start small, but may eventually stock 50-150 meds)
• Obtain lab contract & pricing: typically done via “client billing” arrangement
  • First check your state’s laws. Some states make difficult or have restrictions.
  • Possible companies: Quest, LabCorp, Physicians Reference, Local lab -- ask local mentors)
  • Pathology: (can potentially be tricky d/t legal restrictions)
• Create repository of clinical worksheets/forms
  • ADHD Evaluation, PHQ-9, Epworth Sleepiness, ASQ, etc.
• Storefront Sign & Sign permit
• Internet service
  • Broadband options and requirements
• Office network
  • Wired vs. Wireless
• VPN/remote access
• Backup procedures: onsite, cloud, offsite

13. Medications (if applicable)

• Dispensing license regulations by state
• Create account with wholesale medication/medical equipment supplier - Vendor options: Andameds, Henry Schein, McKesson, Bonita
• Decide on medication formulary (what you will stock)
  • Make initial order (most practices will start small, but may eventually stock 50-150 meds)
• Order meds, bottles, lids, other supplies
• Consider pill counter vs Pilleye App vs other

14. Labs/Imaging

Client billing for labs/pathology/imaging not legal in all states

• Contact Quest, LabCorp, CPL and ask for “client bill rates”
  • Consider using GPO/GPP
• Contact local imaging centers for cash list of all services offered
  • Ask about possible “client bill” discounts
• Contact local pathology companies
  • Consider MC Pathology for basic pathology needs

15. Open Clinic

• Start seeing patients
• Continue online and offline marketing
• Plan ribbon cutting ceremony through Chamber of Commerce 3-6 months in

There are many considerations that go into whether you hire a virtual assistant or an in-office employee. Some considerations include the work you need done, how your office is physically set up, your desire to manage payroll and payroll taxes, what you can afford, and how you communicate best with others.

Work Needed:

Take some time to make a detailed list of what tasks you need your employee to manage for you. If you need their assistance with filing of paperwork, completion of prior authorizations and pre-certifications, and contacting patients with results this can be completed by either someone in the office or virtual. If you are comfortable with the work being done in an asynchronous set up (ie the work can get done at their convenience rather than at hours directed by you) a virtual assistant would be a good option. However, if you need someone to room patients, collect vitals, draw blood, and assist with procedures you will need an in-office assistant. If you prefer the work to be done during specific hours/times, virtual may be an option, but in-person may be better.

Office set-up:

Does your office have space to comfortably have an additional person in there? If you are working in a small 500sqft space, you may not realistically have space for you and an in-person staff member. If you have enough space, do you have any space for them to “get away” for a few minutes? Even something as small as a kitchenette for them to sit in and get away from their desk for a few minutes can make a big difference in their overall happiness at the office.

Payroll Management:

Do you want to manage employee payroll and taxes (unemployment, workman’s comp, etc)? If you hire a virtual staff member you have the choice of paying them as an employee or as a 1099 depending on your expectations and working agreement. However, it is much more complex to pay an in-office employee as a 1099.

Financial Capabilities:

With virtual staff you have the opportunity to hire someone based outside the US. Often, a living wage for virtual assistants outside the US is significantly lower than one based within the US. If you find yourself in the situation of needing help but uncertain if you can support cost of in-office staff, a virtual assistant based outside the US may the perfect solution.

Communication Preferences:

If you are the sort of person who is comfortable with electronic communications virtual staff is a great option. However, if you greatly prefer in-person interactions and conversations, you would likely do better with an in-person staff member.

In summary, when deciding to hire virtual vs in-person support staff, it is important to know what you need, what you want, and how you would best function and hire accordingly. If you know you need help with rooming patients, it would be silly to hire someone to work virtually. In contrast, if you know your office is too small to comfortably have a second person present regularly, it would be silly to hire an in-person staff member (unless you are actively enlarging your space and have real plans and timelines in place).

What are the top 35 lab tests that most DPC doctors order? 

• CBC
• Complete Metabolic panel 
• Basic Metabolic panel
• Lipid Panel
• TSH
• Free T4
• Hemoglobin A1C
• Urine microalbumin
• Urinalysis
• Urine culture 
• CRP
• ESR 
• ANA
• Vitamin D
• Vitamin B12
• Iron
• Ferritin
• TIBC
• Testosterone
• FSH
• LH 
• Insulin level 
• PSA 
• FIT test 
• Stool culture
• Stool O&P
• C. Diff toxin 
• Uric Acid
• Acute hepatitis panel
• Gonorrhea and Chlamydia TMA or PCR 
• Vaginitis panel 
• HIV
• RPR 
• D-dimer 
• Intact PTH

In a traditional, insurance-based practice, you may need to cancel existing insurance contracts prior to starting or joining a DPC practice. In that process, there are a few considerations.

First, it’s advisable to obtain and review all of the active insurance contracts--whether you are self-employed or employed. Of note, many insurance contracts are “auto-renewing” and will often remain in force until you pro-actively cancel them.

EMPLOYED? Some employed physicians do not sign insurance contracts as individuals; rather, the contract is with the business entity (hospital or medical group). In that case, if you leave the practice, you would not need to cancel the contracts. However, you must clarify this with each contract and your employer, because, in some cases, the individual physician is signing a contract with the insurance plan.

TIMELINE. Once you get the contracts, you should search through them to find the “terms of cancellation” or similar section. Some may be canceled within 30 days, while others could require up to 1 year of notice! Most commonly, the effect of cancellation is in the 60-90 day range. In any case, having this information will be required as you choose the start date of your new DPC practice.

NOTICE OF CANCELLATION: You will need to find out what is officially required to cancel a contract. While several options may be permitted, the safest option to ensure cancellation is to mail a certified letter. Make sure you send it to the correct address and get confirmation. It is advisable to call after 30-60 days to confirm the cancellation was processed.

DEPENDING ON TIMING you may not be able to recruit certain pts until the contract with their insurance ends. You aren’t required to still see these pts and bill their insurance, but you should be aware that abandoning them is not allowed either. In your notification letter, you might consider educating your pts to begin looking for other PCPs available to them. You could also see the pt and continue to bill the insurance or see them for free until the contract terminates. You can pick and choose which pts to offer these options to. Be aware that they may not convert to DPC with you no matter what but the longer you continue to care for them the better your chances.

VISION

In deciding to transition to DPC, it is necessary to have a clear vision for what you want to create and why you want to create it.

1. How does this vision:
   • Benefit your patients?
   • Benefit you and your family?
   • Improve the practice of medicine?
2. Why is this transition necessary for you?
   
3. What would happen to you if you did not transition to DPC?

INTEGRITY

Nothing sells better than integrity.

• Figure out your why, simplify it, and don’t look back.
• Your vision, your model, your why, and your passion for patient care will shine through as you transition to DPC.

PRACTICE YOUR SELLING PITCH

Selling often seems unfamiliar and uncomfortable for physicians. However, every physician-patient interaction is an exercise in trust and is a type of “selling.” Be authentic, not apologetic.

• Learn how to describe Direct Primary Care and your practice in 30 seconds or less
• Practice on family members and friends
• Ask friends in marketing to listen and provide advice
• Teach your family, friends, and office staff how to present DPC quickly and confidently
• Fake it till you make it - practice really does make it easier
• Check out marketing videos on other DPC physician websites
• See How to Create a Great Elevator Pitch for more details

BECOME COMFORTABLE WITH MONEY - KNOW YOUR WORTH

• To figure out your rates, see Setting Membership Pricing for some useful tips
• Do not undervalue yourself
• Present your pricing in a confident manner
• Use analogies that others have used before you, “ for the price of your cellphone bill”, “the Netflix of medicine”

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.

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.).

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.

“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.

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.