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.

Integral to any relationship is good communication; your relationship with your patients is no different. Before picking your software and platform for communication first decide your priorities for communicating with patients:

• Will you allow texting with patients? If so, during what hours? And for what concerns?
• Will you allow direct emailing with patients? If so, for what concerns?
• Will you utilize a patient portal for messaging with patients?

Additionally, there is one big law that governs communications with patients: The Health Insurance Portability and Accountability Act (or: HIPAA).

• The Department of Health and Human Services has information about patients exercising individual choice regarding communication linked here.
• DPC Frontier discusses the nuance of HIPAA in the context of running your DPC practice.

Understandably, HIPAA is a complex subject that likely warrants consultation with your attorney.

Once you get past the legal hurdles and decide your communication preferences, there are many software vendors that help you communicate with patients.

• Spruce
• AtlasMD
• Google Suite (email, forms)
• + various other secure messaging apps -- just do an online search to see what’s out there!

Once you decide how you are going to communicate, you need to educate your patients.

One of the biggest benefits of direct primary care is the fact that it removes episodic, transactional billing and provides a more fluid, easy-to-administer monthly fee.

Several vendors can assist in the monthly billing process. The ones that can cater to the DPC marketplace are:

• AtlasMD (EHR)
• Hint Health
• Twin Oaks
• Cerbo (previously MD-HQ) (EHR)
• Square
• And many more…

Beyond the monthly billing, other items require billing your patient. A far-from-comprehensive list may include:

• Labs*
• Imaging*
• Medications (see DPC Frontier for state-by-state regulations)
• Pathology* (see DPC Frontier for state-by-state regulations)
• Durable medical equipment
• Medical supplies (i.e. stitches, casting, etc.)
• Enrollment fees, after-hours visit charges, etc.

*There is a concept, called “client billing” where a vendor bills you, the practice, and you pass the charge on to the patient. Many vendors use this setup to offer your practice -- and subsequently, your patients -- below-list-price prices. Other vendors offer direct, patient billing. There are pluses and minuses to each setup.

With any of these options, consider the time requirements, scheduling conflicts with DPC clinic time, pay, your existing skillset, malpractice coverage, and whether it requires Medicare participation. Malpractice coverage is required for every clinical position. Make sure you are covered both in your DPC and your moonlighting position and get separate coverage if needed. Regarding time commitments, DPC patients expect good service and part of that is doctor availability. Plan to meet or exceed those expectations, and remember your long-term plan when choosing a side gig. Any option that provides adequate income and fits your skills, interests, and schedule increases your chances of DPC success.

When a patient needs to get lab work outside the scope of your practice’s in-house capabilities, there are several options to consider:

• CLIENT-BILLING: This is what most DPC practices have in place with a lab company to ensure transparent rates and avoidance of insurance hassles. This is effectively a “passthrough” where the lab company bills the practice rather than the individual patient. Client billing is allowed in most states, but a few have restrictions. Setting up this option for your patients, insured or not, is typically the most affordable option for your patients. (See article Arranging Client Bill Labs for more information).
• LOCAL LAB WITH INSURANCE: If a patient has an insurance plan, you can give them an order and visit a local lab that will bill their insurance as usual. This process can, of course, be filled with many pitfalls and caveats for the patient and doctor. For example, the patient and physician may not know which labs are in-network or out-of-network. Some insurances may have limitations on which labs can be drawn or how often. And there may be unexpected costs associated with this option. Additionally, the physician will be required to supply diagnostic information not required for the other options (ICD 10 codes). If a patient chooses this option, the best advice is to urge caution and keep expectations low.
• LOCAL LAB WITHOUT INSURANCE: Sending a patient to a lab without insurance is likely to stick them with a bill with “chargemaster” (3-10x insurance) rates. This is not advisable unless the lab company has a transparent, “self-pay” option in place (fairly rare).
• ONLINE LAB SERVICE: Many online companies will sell labs, often without a physician’s order, directly to patients (for example Ulta Labs). Many of these companies are basically resellers who use a lab company (e.g. Quest or LabCorp) to perform the actual lab and deliver results to the patient. On average these will be more expensive than client-bill rates, but less than chargemaster rates for uninsured patients.

A question asked frequently within the DPC community is whether or not you can successfully open a direct primary care practice in your own home.  It is a natural question to ask since, in many ways, the DPC model is ‘going back to the future.’  We are trying to recapture the spirit of the old-time family doctors who cared for many of us and our families in generations past.  Many of these physicians had offices attached to their homes and were very successful.  The question is whether or not that can be done today.

There are a small handful of DPC physicians who are practicing in a home office and are very happy doing so.  There are several pros and cons, and many factors to consider before going down this road.  We do our best to outline them here.

Without a doubt, the first thing to examine is how would having a practice within your own house affect your family?  If you have a spouse/significant other, are they on board with this concept?  Will working out of your home improve your relationship because you may be home more because you have no commute?  Will it hurt it because you have a hard time walking away from work and respecting home/work boundaries?  Is your spouse/partner going to work in the practice with you?  Some love the idea of just going down the hall to go to work and being able to have lunch in their own kitchen or a nap in their own bed.  On the other hand, some prefer clear delineation between home life and work-life to promote balance.

If you have children, how will this affect them?  There is a definite advantage to working out of your home if you have young children, especially if both parents work in the practice.  It would allow you to check in on the children throughout the day.  If a child is home from school sick, it is easy to keep an eye on them without having to take a day off.  Older patients often love to see the doctor’s children coming in and out of the office.  It promotes a sense of family in your primary care practice.  On the flip side, some physicians prefer not to have their children underfoot, and to maintain boundaries between patients and their private lives.  If the children tend to be noisy, that can irritate you and the patients. There are also considerations in terms of whether or not you want to have your children potentially interacting with strangers in your front yard.  It is also important to have you think about keeping your front yard free of loose toys, bicycles, etc.  It detracts from a professional appearance and can create tripping hazards.  Also, your pediatric patients might help themselves to play with your children’s toys, which may not be ideal.

The second issue to research is whether or not local town ordinances will permit you to run a medical office out of your home.  In our experience, the codes often vary widely from one town to another.  In many cases, home offices are allowed by the municipality if they do not take up more than a certain percentage of the house’s square footage (i.e. 20-25%).  Some towns might restrict the absolute amount of square footage that is used for the office space.  It is not uncommon in cities and suburbs to require that the business have a certain amount of off-street parking, which is usually based on the square footage of the business.  There may also be constraints on signage in order to maintain the residential feel of the neighborhood.  Some towns also have a cap on how many employees can work in your office who do not reside in the home.

If after doing this research, you find that you would not meet your town’s criteria for being considered a home office within a residential area, you might have to investigate what it would entail to have your property rezoned.  Some localities recognize a residential/professional designation, which is ideal for what you would need.  It means that a home can be used for either purpose at any time.  If your town does not have this option, you might have to look into petitioning to have your property rezoned for business purposes.  Depending on whether or not your town hall is business-friendly or not will determine how difficult this process might be.  In order to test the water, you might want to speak to your local code enforcement or planning department to see what they require.  Some towns will allow a single parcel to be rezoned to accommodate a business, but some would require that a whole group of them convert.  The process would require a formal application, meetings with the planning committee and town council, as well as soliciting input from your neighbors regarding their concerns about the proposed zone change.  It is sometimes beneficial to discuss the process with an attorney with experience in this area.  If you need to go through this process, it can take several weeks or months, so please factor that into your plans.

It is important to check with your homeowner’s insurance company to see if you will need to add a rider to your current policy to allow for a home business.  There is a chance that they cannot cover you at all, at which point you would need to talk with a broker about a new policy.  This may be an inconvenience, but not the end of the world.

The optimal arrangement for a home office is to have a space that is completely distinct from your living area, with a separate entrance, which is clearly marked so that patients do not go to the wrong door.  As a home office, there is a good chance that you will not need to be ADA compliant, but it is still a good idea, if possible, to be as handicapped accessible as possible.  You might want to consider a ramp if the door is not at ground level.   If your office space needs structural renovations, you may need a permit and certificate of occupancy from your town.  You can expect a visit from your local fire department to be sure that you have fire extinguishers, emergency lights, and fire alarms in the areas open to the public.  We will not discuss office design or space requirements here because every practice and physician is unique.  

The financial advantages to a home office are many.  You should talk with your accountant for formal advice because there are many different approaches and each may have its own advantages.  Some examples given by one physician who practices out of his home are: it is legitimate for you as a homeowner to charge the practice rent.  This will allow you to defray a portion, if not all, of the cost of your mortgage as a business expense.  In order to do this, you should have a formal lease.  You may be able to pay some of your utility bills as a business expense.  You may also be able to declare a portion of your home improvements, landscaping, and other expenses and supplies necessary to maintain a professional appearance to your building.  (Please consult your accountant for formal guidance.)

Frequently, the question is asked about practicing medicine out of your home is about patient boundaries.  This generally is not as big an issue as one might suspect.  The key to success is to clearly establish boundaries early on.  If the office entrance is clearly marked, it is not likely that patients will be knocking on your front door.  Patients tend to be extremely respectful of your private time.  Occasionally, patients may broach the subject about dropping by to see you after hours but frame it as a joke to feel you out.  It may just be a joke, but it is usually best to make it clear, in a friendly way, what your boundaries and expectations of privacy are.  It may sometimes be a challenge to enjoy a day off during the week and be in your front yard and have a patient stop by unexpectedly to ask a question, pick up a refill, etc.  In most cases, simply letting a patient know that you are enjoying private time and that it would be better if they call before coming over is perfectly fine.  The same applies to pharmaceutical representatives.  Realistically, the best way to avoid interactions such as this is to not be visible during personal time taken off during your usual business hours.  Stay in the back yard, in the house, or away from home.

In summary, there are many things to consider and research before opening your medical practice in a home office.  It is a unique situation with many advantages and a few caveats.  It may not be a good fit for everyone, but for the right physician and their family, it can be a fantastic arrangement.

Before employees chose your DPC clinic they will have to go through an “open enrollment” process. This process occurs yearly and allows time for benefits advisors and employers to explain all the employee benefits. These are usually long, boring meetings but do offer critical time for employees to ask questions and understand their health plans. Getting involved in this open enrollment process is a must for DPC docs as it is crucial for starting a relationship with employees (and employers -- they will be patients too).

You should ask the employer and the benefits advisor to keep you involved and plan for time off to attend those meetings. Ideally, they will allow you time to speak at open enrollment to share your DPC passion with employees. Plan to be available to answer employee questions at the end of this meeting.

(This will likely blow employers’ and employees’ minds, as they have never had a physician actually come speak to them about anything -- let alone about increasing access to care and lowering costs!)

Open enrollment meetings are a great time to “meet and greet” some potential new patients!

You landed a new employer which potentially could add dozens or hundreds (!) of new patients in a few months, now what? How do you get all those people into your EHR system and into your office for initial visits? Here are some tips:

• Plan ahead for busy schedules (leave open schedules, limit time off)
• Prepare the staff for new patients (add new staff? adjust work hours?)
• Get patients registered In your EHR ASAP (educate employee and employer here)
• Try designing cards to be given to employees with simple directions on how to sign up on the DPC EHR
• Build basic “skeleton” charts for all the patients that did not sign up online
• Schedule initial visits for all employees, as soon as possible -- think about sending reminders via text and/or email to encourage people to come in.
• See sick visits and refills as needed even if initial visits not done
• If possible, don’t onboard in the middle of cold and flu season

Adding lots of new employer patients will be time-consuming but proper planning can be done in a few months. Be sure to let the employer know about your onboarding plans and get involved in the open enrollment sessions to provide clear communication with your future patients is the key.

The diagnosis and treatment of Obstructive Sleep Apnea can be achieved at a more affordable rate through cash pricing.

TESTING:

Home Sleep Apnea Testing (HSAT) services will mail the HSAT equipment to your patient’s home, where the patients hook it up, sleep, and mail it back. Reports are mailed/faxed to your office. Prices are currently as low as $125. Several companies offer this service, and the DPCA has partnerships with two of them, Somno and OwnSleepMed.

TREATMENT:

Auto-CPAP equipment with additional supplies (mask, filters, tubes, etc.) is available for around $600. Also, look for used equipment on sites like eBay.

Note: Patients of DPC Alliance members can get a discount on OSA-related equipment via our Vendor Partnership with TerraCore DPC. This negotiated discount is a member benefit. The DPC Alliance receives no direct financial benefit from any of our vendor partnerships. Learn more about our vendor partnerships here.

During your transition to your DPC, you will want to notify your existing patients about the change. If you have a non-solicitation clause in your agreement, you have to be careful how you do this. Before announcing your departure, there are some ways to circumnavigate this and maintain contact with patients without breaking your non-compete clause. Check your contract - does your non-compete clause include email addresses and social media connections?

CONNECT WITH YOUR PATIENTS ONLINE BEFORE YOUR ANNOUNCEMENT:

• Open social media pages on all platforms and “friend” your patients from those (check your contract, some employers have shut down social media networking with patients)
• Start your website as a physician (not the name of your new DPC….yet)
• Consider posting some blog posts about health topics on your website/blog
• Ask friends to share your posts so that patients can see them too
• Join all the local community groups on social media with your full name and participate in some discussions. Patients will start to take notice that you are there.

EMPLOYED PHYSICIANS - TRY TO NEGOTIATE NON-SOLICITATION CLAUSE:

Most employers may restrict your ability to notify patients about a new (competing) practice. However, that is not universally true. It’s best to have a conversation with your employer to get the best terms possible.

Consider using the discussion point that your DPC practice will be totally different from your current FFS practice. You can argue that because the new practice will be so different you won’t be competing against each other. Each situation will have different results depending on the hospital and administrators. The best-case scenario is to obtain the contact information (mailing address and emails) of all of your patients. You may want to prepare for a negative outcome, that they say no to patient solicitation. Before you announce your departure, there are some ways to circumnavigate this and maintain contact with patients without breaking your non-compete clause. Check your contract - does your non-compete clause include email addresses and social media connections?

IF SOLICITATION IS PERMITTED - ANNOUNCEMENT(S)

• HOW MANY? Send at least 2 notifications (letters, emails, or other) to create some anticipation and build-up to opening your DPC practice. This can be a great marketing strategy and ease potential shock patients.
• CONTENT: Your announcement should include, and likely start, with your “why.” Let patients know the reasons why you have decided to switch to DPC, namely, to provide better care to them! This will help incite an emotional and human response from patients. At the end of this letter, create some anticipation, with a teaser and sign-off with “stay tuned” or “more information coming soon.”
• FOLLOW UP: Your subsequent announcements should give more detailed information on your DPC practice, including timeline, website, how to sign up, and contact information. You can also use this letter to invite each of them to an informational meeting or town hall to help answer their questions about DPC.

MAILING LETTER(S)? It can be expensive to send letters to each patient or family when you have thousands of patients, so most physicians elect to only send one letter. You can use a local mailing service or you can recruit family, kids, or friends to help you stuff envelopes. This can be very time-consuming but can save you money on start-up costs if you have the time. Conversely, if you have enough money to use a service, this can save you significant frustration and time. Remember email is much more affordable, but at least one mailing would be appropriate. To invite patients to events you could consider postcard type mailing which is much more affordable.

SPREADING THE WORD IF YOUR NO SOLICITATION IS IRONCLAD

• Continue to post health blog posts and share them on all your social media
• Monitor your community social media groups and if patients post asking about where you went, recruit a good friend to answer the post with your details
• Get involved. Offer to give a talk at your local business association/community center/church on medical topics. Give your new cards out and ask your community to spread the word.
• Solicit newspaper or television media to write an article or do a TV news piece on your practice. Share it on your social media and ask friends and family to do the same.
• The power of social media reaches far beyond the non-compete. As long as the patient finds you, and not the other way around, your non-compete patient solicitation clause has not been violated.

NON-COMPETE RADIUS:

• Patients will travel for medical care from their physician that they trust, especially when DPC allows care to be done easily through telemedicine.
• Find the location that suits you best. Take a 2-year sublet or lease. Once your non-compete is up, you can decide to move your DPC location closer to your original patient panel. Who knows, maybe your new location will suit you better.

SAMPLE NOTIFICATION AND TRANSITION LETTERS (DPCA members only)

1. Transitioning to DPC from Private Practice Letter - Written by Debbie Sutcliffe, MD (members only)
2. Transitioning to DPC from Employed Practice Letter - Written by Kissi Blackwell, MD (members only)

As of 2020, roughly 400 physicians commit suicide annually. More than 40% of primary care physicians’ time, by some estimates, is taken up with non-clinical activities. Burnout and moral injury are oft-discussed phenomena regarding the physical and emotional toll practicing medicine has taken on physicians. Put simply: current healthcare constructs fail to provide a therapeutic environment for the patient and physician and, most importantly, for the physician-patient relationship. Direct Primary Care (DPC) is one practice model that focuses on the physician-patient relationship where the incentives of both parties are aligned. The chasm between being an employed physician in a traditional health care setting and going out on your own to open your own small medical practice can seem exceptionally vast. However, many physicians are returning to solo or small group independent practice and are sharing their experiences on how to do so successfully. DPC restores physician autonomy, affords the same and next-day access, and is empowering primary care physicians to remain inspired and empowered.

Why Dispense?

One of the best ways to bring value to your DPC membership is to dispense prescription medications out of your office. It saves patients time, energy, and (most of the time) money to get their prescriptions from your office. 

Physicians can currently dispense prescriptions out of their offices in 45 states. The rules and regulations for dispensing varies drastically by state. DPC Frontier which is managed by Phil Eskew DO, JD, MBA has an extensive listing of each and every state that he keeps track of.  (https://www.dpcfrontier.com/dispensing-medications). The five states that currently dont allow physician dispensing are NH, MA, NJ, TX, NY (even in these states there are some “emergency” situations where short term prescriptions can be dispensed. 

For the rest of the states, after you have complied with your state regulations, you should strongly consider providing this service. It is extremely valuable for a sick/acute patient to be able to get what they need at the visit rather than going to the pharmacy to wait for an hour or more while in pain or ill. 

Similarly, dispensing chronic medications is valuable for patients. Many DPC offices will buy drugs in bulk just like a pharmacy and sell them at very little or no profit. Patients will often save enough money on several prescriptions to pay for most or all of the DPC membership fee. (example: lisinopril is currently 5 cents/pill. 100 of them would only be $5). This provides VALUE to your membership. Many of your patients would rather spend their money with YOU to support your small business and you. Dispensing medications allows you to keep better track of compliance as well. 

Also if you get your system streamlined, you provide ease of ordering and picking up medications. Patients will communicate by text, call, email or any of the above to request refills. Most offices will fill non urgent meds within 1-2 days. Usually their software or EMR tracks the meds and billing allowing patients to just put the meds on their account. This makes it easy to just come in and pick them up without long lines and wait times at a pharmacy. Some offices will buy or add some sort of “lockbox” on the outside of their building for after-hours pickup when necessary. 

How to Dispense

There are multiple online distributors that will sell meds (and bottles) in bulk and deliver them to your office. Andameds, Bonita, Henry Schein to name a few. With most of these suppliers, you can create an account and pay weekly or monthly for the supplies you buy. 

Something to consider is what pill counts to order. If you buy in bottles of 1000s then you or your staff must plan a way to count out the right amount of pills. You may need to buy a pill counter (https://rxcount.com/rx-4/. They run about $2500). Another option is to buy in 90 or 100 count bottles. Then you dont have to count. You do need to be aware of your state law on the type of container needed to dispense. Most have to be child proof.

Prescriptions also need to be labeled. You’ll need a label printer. (Dymo and Brother are a couple of the label printer companies to consider). Connecting the printers to your computers requires a little bit of tech know-how. Most of the inventory tracking and managing will populate the labels with the information. The majority of EMRs that are used in the DPC community do the inventory and billing directly, but there are other software programs that cover this as well if needed. 

A few docs also team up or hire a local pharmacy or pharmacist to manage the dispensing. The main concern about this is making sure that they provide good value to the patients. Otherwise it would be the same as any other pharmacy they already have access to.

A new DPC practice does not typically provide the same income as a traditional practice. When starting a DPC practice--whether out of residency or leaving a traditional or employed practice--a strategy for additional income sources is essential. Having adequate income outside the DPC practice can be the difference between success and failure. Don’t put your ultimate freedom in jeopardy by not having a viable plan. Even if you plan to use loans or savings to subsidize your income, having other possible revenue sources can help if growth is slower or costs are higher than expected.

Do what you know: If you’re already moonlighting in an ER or urgent care--or have before--that’s a natural place to start. If not, there are plenty of options for a primary doctor willing to hustle.

Most DPC doctors are opted out of Medicare. Learn more about opting out of Medicare. Many DPC docs who are doing moonlighting/side hustles will wait until their DPC is more established to opt-out because opted-out moonlighting is more challenging and bamboozles administrators who’ve never had to figure out how to make it work. For those who have opted out of Medicare, DPC Frontier also has a great resource on Opted-out moonlighting, here.

Deciding how you wish to handle Medicare is a huge step for those entering DPC. There are several excellent resources on how to opt out of Medicare and the consequences of doing so.

• Dr. Phil Eskew’s DPC Frontier has the go-to resource for legal issues on this matter.
• To learn how to opt out of Medicare, watch this video.

The more important discussion here is why and when to opt out of Medicare. In order to offer full-scope DPC for all patients, you must eventually opt out of Medicare. Until you opt out you either cannot see Medicare patients, or you must bill Medicare for your services. Some small loopholes allow for billing Medicare patients for non-covered medical services, which is a tactic utilized by many concierge practices, but if you wish to consider this you must speak with an attorney to ensure you are set up correctly.

Many physicians starting out worry that they will struggle to enroll Medicare patients into their DPC, so they choose to remain opted-in during start-up. However, if your end goal is to be full-DPC, it may not be a great plan long term to do this as you will eventually have to make the transition, and it may be harder to explain the change to established patients than it would have been to enroll Medicare patients directly into DPC from the beginning.

When deciding the right time for you to opt out, one of the major decisions is whether you anticipate moonlighting. Most moonlighting opportunities require you to be opted-in. Medicare does not allow you to opt-in at one location but opt out at another. Thus if moonlighting will be important for you financially, you may choose to delay opting out. (See this Member Only article Moonlighting and Side Hustles for more information)

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. Effectively, once you decide to opt-out you should assume you are opted-out for 2 years because opting back in within the 2 years is extremely difficult and rarely successful.

Finally, 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.

There are many different ways to advertise, and what works for one office may not work for another. When developing your marketing plan, the first step is determining who your target audience is. Without defining a target audience, you cannot expect your marketing to have peak success.

The biggest mistake you can make is thinking “my target audience is everyone” because if it is everyone, no one is listening. So, while you may want a variety of patients and want “everyone” as patients, you should not try marketing to “everyone”.

Part of defining the target audience is evaluating what your ideal patient looks like. Is your ideal patient a young married couple with 2-3 kids? Or maybe your ideal patient is a truck driver who is rarely home and likely to utilize remote medicine more heavily than in-office appointments. Or perhaps your ideal patient is the diabetic hypertensive patient who really wants to improve their lifestyle but struggles to keep to a plan.

Although this is not an exhaustive list, some things to consider when determining your target audience include:

1. What kind of medical care do I enjoy the most? Do I really enjoy lifestyle medicine? Do I enjoy making personal connections and being that connection for people whose family has all moved away? Do I enjoy pediatric care and watching my patients grow into adulthood? Identifying what you enjoy will help ensure you will find joy and fulfillment in your practice.
2. Who is around me? If you want to grow a pediatric practice, but are looking to establish near a retirement community, you might want to look elsewhere or change your target audience. If you are unfamiliar with an area, you can usually obtain general demographic information such as age distribution, gender distribution, average income level, average education level, etc from the local Town or City Hall
3. Look at the current customer base. Where are your current, potential patients receiving their care? Look for common characteristics and identify ways you can stand out among the crowd. If you are establishing in an area where there are very few primary care offices, your advertising will be very different than if you are establishing in an area dominated by multiple large well-known medical corporations.
4. Are there any medical services you wish to offer that currently are not offered locally? For instance, if you enjoy cosmetics and there are no obvious cosmetic medical practices, that would be a great asset to really set you apart.
5. What are the personal characteristics of your target audience? Are they stay-at-home parents? Are they avid outdoors people? Your marketing will be very different if you are trying to reach stay-at-home parents than if you wish to reach avid mountain bikers.
6. Where does your local community congregate? Do they all go to churches? Do they congregate on select Facebook Communities? Do they utilize Nextdoor heavily? Is there a local paper that everyone in the neighborhood reads? This information is key to helping you determine where to reach your target audience. For instance, if they are all on Facebook and you are advertising on Nextdoor you will be wasting your time and money.
7. Evaluate your decisions. You’ve made it this far into identifying a target audience, but is that target audience large enough to warrant spending money to advertise to? Or are you likely only going to get a couple of patients over several years out of that audience?

With all that, remember that you can have multiple target audiences for different marketing plans/goals - but each marketing plan should be directed at one target audience for the best effect.

For more information, consider checking out this link, How To Create A Great Elevator Pitch

Sometimes the best or most affordable option is for a patient to travel to receive specialty care, especially for surgery and other procedures. This is commonly referred to as “medical tourism.” In the past, this has implied leaving the US; however, there are several US surgery centers catering to direct-pay patients.

It is valuable but not always necessary to help your patient navigate this process. Your knowledge of medical tourism options can be very reassuring for patients when this feels very different and may be hard for them to consider the idea. Familiarize yourself with large direct pay centers in the US.

A few of these options for patients to consider:

DOMESTIC DIRECT-PAY SURGERY CENTERS

https://www.surgerycenterok.com/ (Oklahoma City, OK)

https://www.affordableherniasurgery.com/ (Rockville, MD)

https://www.oceansurgerycenter.com/specialties-pricing-torrance/ (Torrance, CA)

https://hpbsurgery.net/Pages/pricing/low-cost-surgery-pricing.html (Winston-Salem, NC)

https://texasfreemarketsurgery.com/ (Austin, TX)

https://www.pacificsurgicalwa.com/pricing/ (Longview, WA)

https://lonestarsurgeryctr.com/pricing/ (Houston, TX)

https://omahasurgicalcenter.net/billing-insurance/ (Omaha, NE)

https://www.nttcsurgerycenter.com/ (Mesquite, TX)

https://www.stgeorgesurgical.com/ (St. George, UT)

INTERNATIONAL DIRECT-PAY SURGERY CENTERS

Traveling to another country for surgery or medical care is a more complex matter with a few special considerations. The CDC has some guidance on this topic.

Here is a map

Non-solicitation clauses in employed practice can be difficult to navigate when you are trying to transition into DPC. Try to find out exactly what the clause states and how restrictive it is. If you are able to let the patient know you are leaving, but not where you are going, you may be able to simply hand them your new DPC business card and direct them to your website for enrollment. In these cases, it is especially important that you have your cards, flyers, and website already created, so it is very simple for patients to find you on their own.

Some clauses are very restrictive and will not allow you to let patients know that you are leaving. In this case, there are opportunities to create a personal brand via social media, podcasting, or blogging. While planning and preparing for your transition to DPC, you can share these channels and content with your patient so they can start following you on your journey. This way, you can eventually let them all know where you will be in a more passive form.

Know the laws and the board regulations in your state. In Texas, for example, you are required to send a letter to all patients you have seen within the last 2 years and notify them of your departure. You can allow the employer to do this for you but since the physician is ultimately responsible, you can elect to do this yourself instead. For physicians in Texas, this is a prime opportunity to alert patients of their new location and practice model. They may even want to invite patients to a town hall type meeting explaining the workings of the new practice inside the text of the letter.

Whether you are employed or self-employed, there are lots of ways you can market to your existing patients while you are transitioning to DPC.

If you are employed, check your employment contract for clauses that may hinder or prohibit the solicitation of existing patients. Read Leaving an Employer for more information.

First and foremost, BE READY!

• Before you start talking about your new practice have a few things in place, including contact information, website, and some practice (business) basics. Read this article to learn more about Branding and Marketing[UPDATE LINK].
• Create and share some print marketing: business cards, flyers, brochures, etc.
• Consider possibly waiving enrollment fees or for patients that sign up prior to your opening date.
• Create a letter for patients to give notice of your transition. Consider adding an event invitation to the letter, such as a town hall event.

Pre-enrollment

• Embed a link to your enrollment/EMR inside your website to pre-enroll patients prior to your opening date.

Once you have everything ready

• Use the time between announcing your transition and your opening date to market to EVERY SINGLE patient. Use each patient visit as a marketing opportunity and practice your 1-minute elevator speech.
• Hand out flyers and business cards during patient visits and direct each patient to your website for immediate enrollment. You might consider letting them know that enrollment will be limited.
• Consider holding one or more events where you explain your practice, answer questions, and enroll patients
• Find networking events, such as health fairs or other community events. You might also consider small business networking, such as BNI, Rotary Club, Lion’s Club, and Chamber of Commerce.

Called “dunning,” many businesses find themselves chasing after unpaid bills. Even in direct primary care, with the streamlined monthly billing, you will find that a certain percentage of charges simply won’t go through automatically for a variety of reasons (think: stolen cards, lost cards, expired cars, insufficient funds in a pre-paid or HSA card, etc.).

For those whose payments don’t go through automatically, a systematic process will both create clarity for your staff and patients and will also allow you to operate in a business-like fashion without letting your big, DPC heart get in the way.

Here is a sample process:

From Allison Edwards, MD | Kansas City Direct Primary Care

Clinic-Triggered Cancellation for Nonpayment (using AtlasMD)

All monthly membership payments to the clinic must be paid via automatic payment (it’s in the contract). If a patient’s auto-pay on the 1st or 5th (we only allow the 1st or 5th) fails, the following ensues:

Notification (numbers indicate days from failed payment -- though we usually start this process on the 5th of the month):

• 0: Each failed payment triggers an automatic email from AtlasMD.
• 5: Names are added to the “Failed Payments” list (a living GDoc) on the 5th (or next business day) of the failed payments; each of these members is called or texted by the front staff. Results of the communication are noted on the list.
• 15: Any balances that remain unpaid after the 15th receive a standard letter via US mail and an identical email noting their failed payment and impending 30-day termination.
• 30 or 31: the auto-payment system tries to charge the patient again at the start of the new month (for last month’s balance + current month’s fee). As detailed above, on the 5th the list is updated with new failed payments, and a note is made of the payments that have failed 2 months in a row. Just as before, an automatic email is triggered by AtlasMD notifying the patient of this (second) failed charge.
• 45: A final letter of termination due to nonpayment is created. The letter is then sent to their primary mailing address & also sent as an attachment to their email address.

Determining the remaining balance & ending the membership:

• Remaining balance = the previous month’s fee + prorated half of the current month’s fee (total = 45 days’ worth of membership following their first failed payment). Proration = $(12*(monthly membership fee)/365)*(15).
• End the subscription charge in their chart & delete the current month’s full charge.
• Add prorated fee, as above, as a miscellaneous charge and label it “Medical Services - (month)” then select “Apply charge to the current invoice?” and “Add payment for this charge?” to (try to) run the card for the remaining balance.

Assigning all files & messages:

• In the files inbox in AtlasMD, make sure that all files & messages relevant to this patient are assigned to them (including the letter just created).

Archiving the patient:

• From the billing section of the patient’s chart, the option to “Add to collections” is selected from the cogwheel. Note: we do not actually send the patient to collections, this is just a designation to separate out those who have a remaining balance with us at the end of their membership.

Adding to the Master Status Report

• We track -- as best we can -- the reasons why people leave the practice. The person archiving every patient will add the patient’s name, enrollment details, etc. to the most current Master Status Report.

When starting your own business/practice one of the more exciting aspects of business ownership is taking advantage of the many tax write-offs available to you. It can be easy to get carried away and get yourself in trouble (audited). Knowing what you can and what you should write-off are keys to avoiding a visit from the IRS. As my accountant told me early on in my practice “pigs get fat, but hogs get slaughtered.” Just like eating cupcakes, moderation is key. In recent years, tax laws are changing constantly and are not permanent. Some of the options listed here are set to expire in 2025. Having a good CPA you meet with regularly is necessary to stay on top of everything. Another thing to remember is that you do not need to feel guilty for avoiding paying taxes. The tax incentives and write-offs the government creates exist to help incentivize business creation and growth, in turn, improving the economy. 

Self-employment tax

• You may be asking, “wait a minute, I thought this was an article on write-offs?? A tax as a tax write-off?” Well, this one is ​​a little confusing to me as well, but as a business owner, you have to pay an additional 15.3% tax on the salary you pay yourself, on top of your normal tax bracket. If you were an employee, you would pay half and your employer would pay half. The good news is that you can deduct half of the self-employment tax from your net income when you calculate your income tax bracket. As a business owner, you can help minimize this tax though by paying yourself the lowest salary you can while taking the remainder of your pay through owner draws (if you are filed as an S-corp). The catch is that you have to pay yourself what you would pay someone else to do your current job duties. The IRS may let you get away with not paying yourself a salary for several years, but it will raise red flags if you pay yourself via owner draws for too long. A CPA can help guide you when you need to start taking a salary. 

Home office

• In my opinion, this one can be tricky and maybe more trouble than it’s worth. There is the standard and the simplified method. Your home office space has to only be used for your business. It has to be used “exclusively and on a regular basis, as your principal place of business.” It cannot be larger than 300 square feet. With the standard method, you can deduct the percentage of your expenses for the house. Including utilities, home depreciation, etc. The simplified version allows you to deduct $5/sq ft or up to $1500. If you do decide to set up a home office you can also reimburse yourself for mileage driven from your home office to your main office, and this is not countable as taxable income. I would run this by your CPA first as the “principal place of business” line would likely make it hard for most people to qualify. 

Clothing

• I got into trouble with my CPA on this one when I first started. I was attempting to write off any clothes I bought that I MIGHT wear to the office. My CPA pointed out that I could only deduct clothes that I would ONLY wear to the office like scrubs. So, go ahead and buy those new Apple Bottom jeans but don’t try and write them off. 

Meals

• For now, until the end of 2022 you can deduct 100% of a meal as a business expense. You have to be traveling for business, at a conference or entertaining a client. Traditionally you could only deduct 50% of the cost of the meal. When I first started my practice I tried to write off every meal I ate while at work, even if I was by myself, unfortunately that is not a deductible meal. 

Health insurance

• If your spouse is employed and you do not qualify for their plan, you can deduct all health/dental insurance premiums. If you pay for your spouse’s and kids’ plans as well, you can also deduct their premiums. 

Cars

• This is one I tried early on in my practice and found it too involved to be worth it at the time. You have to keep track of mileage and purpose for each trip. I even used an app called MileIQ that automatically tracked each trip. The app made it much easier, but even with it, I had a hard time keeping up. If you are good with tracking/categorizing every time you drive, it can be a significant deduction. You can basically deduct the percentage of the time the car was driven for business-related purposes throughout the year. If you do not qualify for a home office, then the only times you drive from your home to a coffee/lunch meeting, business trip, etc would count. There are some pretty risky ways to be able to write off the entire cost of the vehicle, but as my CPA told me, you’d have around a 100% chance of getting audited. If you’re curious about how this would work, you would buy the vehicle in December to make it easier to ONLY use it for business-related expenses (i.e. leave it parked at the clinic). Then, when you are filing your taxes for that year, you can take the depreciation deduction all within that year and deduct 100% of the cost of the vehicle. If it’s looking like you may owe a lot of taxes in a given year, this may not be a bad strategy, but have all of your i’s dotted and t’s crossed for that audit that is coming. 

Travel

• The main things you can deduct while traveling for business is transportation to, from and at your destination, lodging and meals. Transportation and lodging can be deducted 100% but meals are 50%. The trip must last longer than an ordinary workday and outside the city where your business is located. Make sure you have the business purpose of your trip planned ahead of time. If you are combining a business trip with a vacation make sure you deduct the percentage of the trip that was dedicated to business. 

Event/party at your house

• If you want to host a Christmas party or another company get-together at your house, you can actually pay yourself similar to what you would have to pay to rent out another facility. This is a double-whammy in that you get paid and can write off that expense under the business.

Interest

• This may not be a deduction you want if you can avoid it, but if you have any bank loans, lines of credit, credit card interest you can deduct the interest paid on it. You cannot deduct the full loan payment. However, if it is a loan for equipment or a vehicle, then the combo of interest paid and depreciation typically is similar to the total loan payment each year.

Transfer of, normally, personal expenses to the business

• This is not a write-off per se but it can help decrease your taxable income. Here is a list of several examples:
  • Charging your electric vehicle at your office which allows to pay for your “fuel” through your electric bill at the office. 
  • Hiring your kids to do jobs they are capable of doing like cleaning, then they can contribute that to their college funds. You can also use your kids as models and use their pictures on your website or social media. You can pay each kid up to $6000/year without having to pay income tax. 
  • Contribution to a retirement plan. You need to be saving for retirement anyways!