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.

Many topics affect DPC as a model, you as a physician, and your patients. This list is ever-changing of course, and depending on the political climate, certain issues are of more importance than others. Following specific issues depends on an individual’s time, energy or passion. However, don’t forget the importance of grassroots advocacy, and know that physicians can play a big role in advancing these issues if you are inclined. The DPC Alliance does not participate in supporting or opposing specific legislation. 

Here is a brief list of issues that are pertinent to our model that have come up over the past few yea

• HSAs/HFAs
• The state insurance board
• In-office medication dispensing
• Business taxes (specifically for professionals)
• Threat of liability lawsuits
• Scope of practice expansion (NP/PA and practice rights)
• EMR mandates
• Mandates for accepting insurance or other payers (ie., Medicaid/Medicare)
• Regulations regarding pharma and medication pricing
• Regulations regarding health insurance requirements for individuals

One DPC resource that has a wealth of knowledge regarding healthcare policy issues is DPCfrontier.com. This is an independent DPC physician-owned website and is a great resource for new and old DPC physicians alike.

Working with employers can lead to some legal concerns that are best handled with plenty of research and lead time, if possible. These issues, especially if employers are large (50+ employees) or offering health insurance, can be complex; varying from state to state.

With many employers, there is no simple way to hash out all these legal issues without the help of a lawyer well versed in employer plans and DPC.

Many mid to large-sized employers will be using self-funded plans, and there are legal requirements for those to protect employees -- like ERISA (Employee Retirement Income Security Act of 1974). ERISA is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. There are specific rules to follow here for employers and for brokers/advisors which may also involve you, the DPC physician. So, the employer will need legal help to be sure they are following the rules and you will need help to be sure your contracts with the employer are correct.

You need to have a DPC knowledgeable lawyer to help you here. Contact the DPC Alliance if you would like help finding one.

If you are currently employed by a clinic or hospital, prior to leaving, you’ll need to consider a few things, including your contractual obligations.

CONTRACT: Hopefully, you have a copy of any contract you signed, but if not, you have to ask your employer for a copy of it. Once you have the contract, you should review it with an attorney to find any potential legal problems in leaving or starting your new DPC clinic. A few specific issues often come up:

• NOTICE OF TERMINATION PERIOD: Most contracts will contain a minimum length of notice for termination; 30-90 days are most common. You need to know that specific time to plan your leave.
• NON-COMPETE CLAUSE: Many employment contracts include a clause that restricts a physician from practicing elsewhere after leaving. These are called “non-competes” and restrictions can include a scope of practice, duration, and geographic locations (i.e. not within a 100-mile radius).

In some situations and states, non-compete clauses can be difficult to enforce. For a review of this, read this article from DPC Frontier. Regardless, these clauses are often used by an employer to scare a physician from leaving or starting a business that poses competition.

• NON-SOLICITATION: Some contracts may prohibit you from directly marketing your (pending) new practice to an existing patient. Obviously, this can be difficult to enforce, but best to understand the terms and what is permitted.

Regardless of your contractual obligation, it’s always best to sit down with your employer (clinic owner, manager, administrator, or other boss(es)) and have a discussion. Leaving on amicable terms when possible is best.

Review this article on terminating insurance contracts.

Abscess incision and drainage is a very simple procedure that should be in every primary care physician’s arsenal.

Most textbooks such as Pfenninger and Fowler’s Procedures for Primary Care teach this skill.

Historically, I&D was performed by cleaning the skin of an abscess with betadine, puncturing the skin with a #11 scalpel blade, evacuating/cleaning the cavity (including breaking down the loculations), and then packing the wound with strip gauze (if you’re not familiar with strip gauze, it looks like a long shoestring made of gauze). The packing would be (painfully) removed and replaced every 2 days until the wound had granulated in.

In more recent years, an I&D technique known as “vessel loop drainage” has emerged that is widely considered the superior treatment option. This technique uses drainage but no packing, which eliminates the need for repetitive and painful packing replacement. (Alliteration intended.) This technique has superior healing times, infection rates, less scarring, and higher patient satisfaction. A video demonstrating this technique is linked below.

The physician only needs betadine, saline, a #11 scalpel, a silicone vessel loop, a curved hemostat, a cotton-tipped applicator, and gauze sponges to perform this procedure. These supplies cost less than $4 total.

https://vimeo.com/19580472

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

Choosing a name for your new DPC clinic may seem trivial but it can be nerve racking for many. Obviously, you want something that sounds catchy and really shares your DPC passion but also is unique. Easy right? Here are some starter tips to get you thinking.

First, start brainstorming with your friends and family. Think about why you’re doing DPC? What is your passion? And just so you know, “Screw The System” is not a good name for your clinic. What about your own personal name, is there something there you can use? Like Gold Direct Care or NeuCare. Think about your community or location, is there something there you can use? Like Hometown Direct Care or Bluegrass Wellness. Write ideas down. Say them out loud. Do they sound good out loud? Be careful about initials, Applewood South Sound Clinic would not be good (let me know when you get that). This example also shows that a name can get too long. Consider searching the DPC Alliance directory for names to get some ideas. And if you are really loaded with cash or crunched for time there are crowdsourcing sites like squadhelp.com that you can pay to help you come up with a cool name.

Ok, you got a name. You think it’s the total bad mama jama. A huge weight has been lifted off your shoulders, and then you go to search for the name among the thousands of clinics, or purchase the name for a trademark or website, etc, and ARRRRRGGGG. It’s taken. So, that is why I say make a list because the next step is to take the list of all the names you came up with and search out your new name on the ole interwebs. Is your name taken already? Just do a Google search. What pops up? Does your search bring up a list of hate groups in Montana? Well, not good. Does your name mean “loser” in French? Again, not good. Check other search engines too.

Next, search your name on the GoDaddy site or another domain purchase site. Can you buy your domain? Just because you don’t see you name come up on a Google search doesn’t me you can buy it. Some names especially some with the words health or care or wellness in them will be premium domains. Is the domain name available and reasonably priced? No debate here on .com or .net or .health domains. Pick one you like and can afford knowing that .com are just way more common. Now check on social media sites like Facebook, twitter, Instagram or LinkedIn? Can you use your name there? You’ll need those later for marketing, though your exact name is not as critical for those.

Finally, you should check your Secretary of State’s website for companies in your state with the same or similar name? If you want to have an LLC or similar in your state you need the name to be available. Also, if you have any ambitions to grow you DPC business into an empire maybe you should consider doing a trademark search. It takes a unique name to be trademarked. Along this line, if you may expand locations or add additional services like aesthetics or counseling would your name still fit? You should think bigger than you are right now.

Your office name is important but it shouldn’t plague you with regret. We hope these simple tips will help guide you to a great clinic name. Be sure to share you name ideas with your Alliance colleagues and get their reviews too. Now, get busy.

One of the greatest benefits of the DPC movement is the collaboration among DPC physicians. Most independent physicians want to help other physicians be successful. Mentorship and the culture of “rising tides raise all ships” has been fundamental to medical education throughout the history of medicine. A good mentor is someone who is enthusiastically willing to share their knowledge and expertise, provides guidance and constructive feedback, and is successful in their own DPC practice.

Resources for Finding a Mentor

Below are two websites which have DPC mappers. Search for DPC clinics in your state and close to you.

• DPC Alliance directory: DPC Alliance Members- physician only
• DPC Frontier mapper: Includes physicians and mid-level (NP/PA), Concierge practices, Corporate DPC practices

You can also do an internet search for DPC clinics in your state and close to you (ie google, duckduckgo, etc).

Social Media:

DPC Alliance Facebook Group

Join online DPC social media groups. There are many state or regional DPC Facebook pages which are great resources to find those around you. Use the search option to find posts about the questions that you have. Post your own questions. Use the files tab to access free resources posted by other physicians. Pay it forward by adding your resources as you build them.

You may find a story from an established DPC physician that resonates with you - for example, a transition practice, a part-time practice, specific practice niches. Do you want to build a practice with mainly uninsured? Mainly employees? Mainly pediatrics? All geriatrics? Do you want a micro practice, without employees? A large practice with multiple sites? Lots of procedures? Find doctors who have built a practice like what you want to do, and reach out to them. Email them and ask to set up a phone call/coffee/lunch date to hear more about their practice.

DPC Conferences:

The greatest value of an in-person conference is meeting like-minded physicians and developing relationships that will sustain you in a path less traveled. Virtual conferences are also helpful but it is more difficult to make those connections virtually. Consider signing up for at least one in-person DPC education event.

• DPC Alliance Masterminds (small group in-person learning with mentors)
• DPC Summit 
• DPC Nuts and Bolts
• Hint Summit

Questions:

• What should I ask of a DPC mentor?
  Ask informed questions - do your own research and read all the DPCA University resources before contacting them. Ask to hear their story. DO NOT ask all the basic questions that you can find answers for here - these physicians are glad to help, but they are grateful when a new prospective DPC physician has shown initiative and done basic DPC research prior to contacting them.
• How should I show appreciation for DPC mentorship?
  Most DPC physicians are passionate and excited about new DPC physicians jumping ship and starting practices near them. The best way to repay your DPC mentor is to PAY IT FORWARD by mentoring the next generation of DPC docs who start up after you.
• What can I expect from a long-term DPC mentor/mentee relationship?
  The DPC mentor-mentee relationship may become a mutually rewarding source of collaboration and support. Be open to sharing tips and tricks with local pricing, vaccines, and supplies, vacation coverage for each other. Be willing to listen when your mentor needs advice and encouragement.

Being an advocate does require a small amount of effort - or a large amount. It all depends on what you are able to do. At the smallest level, you can participate in a letter-writing campaign which is typically started by an organization. The organization will email you a link that requires you to insert your name and contact information then e-sign a pre-written form letter to your legislators (state or federal). These campaigns generally take a minute or two from start to finish, so can be a great way to be an advocate when your time is limited. Helpful tip: you can modify the form letter to include a story from you or your patients to make it more meaningful to your legislator, just keep it brief and HIPAA compliant.

If you’re ready to take it a step further but not quite ready for a one-on-one in-person visit, many medical organizations organize Lobby Days. Typically at a Lobby Day, the organization will help schedule meetings with legislative staff on your behalf and you will meet the staff with a few other physicians. This will enable you to practice meeting with legislative staff members without the stress or workload of setting up private meetings. If this is something of interest to you, you can reach out to your local or state medical organizations to see when their next Lobby Day will be.

However, if you are ready to schedule your own one-on-one meetings, they can be very effective. To learn more about how to contact your legislators please see How to Contact Your Legislator. If you are unsure who your representatives are, you can find them online at USA.gov. When requesting an in-person meeting you can offer to meet them at their office, or invite them to your clinic. Make sure you prepare for the meeting as they have very busy schedules. To get the most out of your visit, a few suggestions include:

• Treat all staff members courteously, as you would expect done at your office.
• Address the legislator professionally (Mayor Doe, Representative Doe, etc).
• Introduce yourself with your credentials – tell them you’re a doctor and where you practice, etc.
• Know the bill number and title and their position on the bill
  • If they are an author/co-sponsor and you are in favor of the bill thank them for their support. If you are mostly in favor but would like to see some changes, thank them for their support then explain why your changes are important.
• Bring with you a brief bulleted handout on the topics you are discussing so they can take notes and take it back to refer to later.
• Use your own words to tell your story and how this will affect your profession and your patients. Your stance should align with their constituents – who are electing them.
• Don’t take notes while meeting with them. Take notes after you leave before you forget what was discussed, but during the meeting maintain eye contact and focus on them. Also, do not ask if it is ok to record the session - it is never ok to record the session (though they may ask to and it is up to you if you wish to allow it).
• Follow-up with a thank you email and answer any questions you did not know the answer to.

An elevator pitch is a brief description of your practice that explains what you do, how you do it, and why the listener should be interested. Crafting a good or a couple good elevator pitches is crucial as many doctors, especially the more passionate ones, will tend to overshare and end up causing the other person to lose interest. 

The key to the elevator pitch is not to include everything, but rather include enough to act as a “teaser” enticing the listener to ask, “Tell me more...” You can explain what you do on a very broad scale and consider including a sentence about what sets you apart from your competition. If possible, personal examples help better engage your listener.

It may be worth having more than one elevator pitch for specific audiences. For example, the “pitch” for businesses vs the “pitch” to someone suffering from chronic diseases vs the “pitch” to an otherwise healthy family interested in continuity of care and accessibility.

An elevator pitch does not need to be a “sales pitch”. In fact, it ought not to be. It should simply provoke enough interest that the listener wants to know more.

Examples for consideration:

“[Business name] is a Direct Primary Care office which means we provide routine medical care to our patients for a set monthly fee. Our prices are upfront and transparent. In a typical medical office, you may not see your bill for 6-18 months, and you will likely be surprised by how expensive it is. Our patients know exactly how much their care will be before they leave the office so they don’t have to worry about how they’re going to afford to go to the doctor.”

“[Business name] is a different type of medical practice where we work directly with our patients instead of their insurance company. This enables us to provide better care and greater access for less money. The last time you were sick were you able to see your doctor, or did you have to go to Urgent Care? Not only can our patients see their doctor the same day, but they can also text or email their doctor directly with questions or concerns.”

“[Business name] does primary care a little different. We limit the number of patients we take care of so that our patients get more time with their doctor and better, more personalized care. This means that all of your children can do their wellness visits at the same time, within a week, as opposed to either waiting 3 months or only seeing one child at a time due to overbooked schedules. Your whole family can get their medical concerns are taken care of at once, which means fewer trips back and forth for you.”

If you want to work with employers, start in your own office! Your patients likely work for someone or own a business. Start there. Can you offer services to their employer?

Next, start looking around your community where employers and entrepreneurs meet. The Chamber of Commerce is a good start. Civic clubs like Rotary, Lions Clubs, or the like frequently need speakers; you could provide significant insight into health care topics -- especially DPC. Church and community groups (your neighborhood development association, the YMCA, etc.) that frequently do health fairs or benefits to raise awareness of certain issues are also great resources. Jump right in there and spread some DPC love.

Other good connections can be made at local business groups like BNI (Business Network International), 1 Million Cups, or LEAD groups. These meetups -- and others! -- connect entrepreneurs looking to grow their businesses. Check these and others out in your community to see if they can work for you.

Finally, social media. You need to have a presence on social media to reach employers using Facebook, Twitter, Instagram, and LinkedIn. Most employers are there on social media and making a name for your DPC practice with frequent posts can get you connected.

One last note, there are benefits advisors are looking to connect employers and DPC -- read about that here.

There are many ways to contact your legislator. Email, phone, or in-person are some of the most frequently utilized. Most legislators have a “contact us” option on their website, and the state and federal government sites have “contact your legislator” forms which are great for sending emails. Old-fashioned letter writing is also an option but generally not recommended as these go through thorough safety screenings before reaching the legislator and their staff. Meaning they will take a long time to arrive. Regardless of which method you choose, here are a few tips for effective communication.

• Read through their website and see if they already have a stance on the issue you want to speak to them about - or if they’ve supported any relevant policy previously.
• If you are calling a state or federal legislator, ask to speak to their health policy advisor/liaison. They are an important part of the communication process because they are who follows the healthcare policy for the politician. You’ll want them to be abreast of your concerns and will often be involved with the meeting with your legislator and taking notes.
• If you are sending an email, make sure the subject clearly states what issue you are writing about to help their staff route it to the correct person. For instance, if you are writing to ask for their support for a specific bill the subject line should read “Please support HB/SB XXX”.
• Be short and to the point. They get communication requests from many people every day and have very limited time to devote to you so do not waste it on unnecessary small talk.
  • Introduce yourself. Being a physician carries more weight with legislators than you may realize, and if they know that a physician is contacting them about healthcare-related concerns they will devote a little more energy to you. Even if you have emailed them or called them before, they will not remember who you are or that you are a physician, so reintroduce yourself every time until they make it clear they know who you are.
  • Explain why you are contacting them, why it matters to you, and why it matters to their constituents. You may be contacting them about a general issue and there is no current policy. You also may be asking them to write legislation (if you can bring a suggested draft that’s perfect) or co-sponsor already existing legislation.
• If you are sending an email, only discuss one issue per email (and do not send multiple emails back to back - you do not want to overwhelm them).
• Always leave your contact info. Whether it’s a business card or handwritten or the signature of your standard email. Include phone numbers, emails, and your clinic information.
• Offer yourself to the legislator as a resource they can use on health industry issues.
• Get contact info for whom you spoke with and follow up with them.
• If you speak over the phone or in person, make sure you send a thank you email and recap what was discussed.
• As your relationship with your legislators and their staff is growing, treat them like you would your favorite patient/relative. Answer their calls or return them ASAP. Kindness and support will go a long way to enhancing the relationship and increasing your influence.

Before meeting with an employer, develop your fee schedule for employers. You can use your current fee schedule -- which some DPC docs prefer -- or you can adjust it. For example, some practices revert to a single fee for any enrolled patient. This single fee for employer-based adults is usually an average of adult fee ranges you offer.

Once you have your fees set, you need a plan to get your money. Like the individual patient agreement, the employer DPC agreement should spell out the fees and how the fees will be paid. Most DPC clinics use ACH to directly draft employer payments right from their bank account once a month. This makes payment simple and inexpensive. You can certainly have employers pay you using other formats like debit card or credit card but ACH is the most cost-effective way.

You should set a payment date and invoice on the first of every month. You can allow the employer to set the payment date, but it is much easier to set one date for all employers (i.e. all payments occur on the 10th of the month). This helps keep all ACHs from employers at the same time. Be sure to share this plan openly with the employer so they understand how the process works.

Physicians transitioning from traditional, insurance-based practice have reported a wide spectrum of success in having existing patients sign up for their DPC practice--from 0-25% based on many factors. But, an average for many private practice doctors (transitioning their entire practice to DPC) is in the 5-15% of their panel in the first 6-12 months of DPC practice. Employed doctors, especially in a hospital or a large practice, have reported less.

Your success will be very dependent on how well you notify and market to your current patient population.

WHICH PATIENTS WILL FOLLOW? Many physicians have noted that the patients they thought would definitely follow them did not, and some of the ones they did not expect to follow them did. Market to every patient in the same way, as you never know who is really understanding the value of what you are doing.

BLOWBACK. You may experience some negative feedback from patients about your leaving traditional practice or not accepting their insurance plans. Expect some anger and frustration. You will have some patients that just will not understand why you are doing this and ones that feel you are probably just trying to make extra money. Try not to overwhelm yourself in appeasing these patients. Do your best to explain your “why” and move on. Many times, these patients come around later, especially when they find that continuing in traditional practice is not as great as they imagined. Word of mouth travels fast and your biggest supporters may actually sway these patients to come back to you, even years later. Do not engage angry patients. Be gentle and let them know that you understand that this model is not for everyone but that you feel it is right for you, your patients, and your family. (See Reaction From Patients for more information.)

Should I pay my staff as hourly employees or can I put them on salary?

The short answer is, “It depends.”

One would think this decision would be a fairly straightforward one, especially if both you and your staff are in agreement. It certainly would be easier to pay your staff members an agreed-upon salary every pay period. Doing this would avoid the need to track hours and submit them every week or two to your payroll company. If you have a good relationship with your employees and they are fine with it, it is hard to imagine that it would be a problem. Unfortunately, this is not the case.

As a small business owner, you must be careful not to run afoul of state and federal labor laws. They have concrete and sometimes not-so-concrete ways in determining if an employee should be considered an hourly employee or an “exempted” employee (someone who is paid a fixed salary). The simple definition of an hourly employee is someone who is paid a certain amount of money for every hour worked up to 40 hours per week, and who is eligible to receive that rate plus 50% for every hour, or fraction thereof, for time worked after 40 hours. A salaried employee, or an employee exempt from overtime pay rules, receives a fixed amount of compensation per pay period, regardless of hours worked.

You should know what the labor laws are in your state, as well as the federal regulations. If there is a discrepancy between the two, the rules that “protect the rights of the employee” will be the ones enforced.

One prerequisite to determine if someone is eligible to be on salary is that they must be paid at least $684 per week. (This amounts to $17.10 per hour or $35,568 per year.). If you are not paying an employee this amount, there is no need for further discussion.

One DPCA member found out during an audit by the U.S. Department of Labor that the hourly rate of pay is not the only consideration as to whether an employee could be on salary. According to that auditor, the role of the employee is taken into consideration as well. If an employee is a worker who does not have the authority to make important business decisions within a company, it is probably best to have them be hourly employees. If it is a local standard for other practices to pay similarly trained staff hourly and you choose to have a salaried arrangement with them, you could be seen as an outlier. This standard may seem a bit vague and open to interpretation, which is exactly why you should be careful not to give an auditor cause to potentially fine you. More guidance from the U.S. Department of Labor can be found here.

According to The Balance Small Business, “… federal law allows employers to consider some employees as being exempt from both minimum wage and overtime pay based on their job descriptions: executives, administrators, professionals, and outside salespeople.” If that description is accurate, then most nurses and medical assistants would probably fall outside that definition, but a practice manager could probably qualify.

The bottom line is that as a business owner, you should ere on the side of caution. If you are in doubt, it is probably best to consider staff members as hourly employees, even if you pay them for the exact same number of hours each pay period. Before you convert them to a salaried position, it might be best to check with your accountant or a human resources professional.

Few will argue that primary care has changed as corporate fee-for-service practices and their payment systems evolved. The average length of a family physician appointment is currently about 8 minutes. It is common for primary care physicians to see over 20, or even 30 patients per day. Many will argue as to the quantity vs quality issues that this change has caused, but one thing is very clear: patients prefer to have more time with their physicians and physicians feel rushed and regularly feel that their job satisfaction, as well as perceived quality of care provided, is worse. And most primary care physicians now have 2,000 patients or more.

In Direct Primary Care, this paradigm has changed. It is not uncommon for DPC physicians to schedule all or mostly one-hour visits, and even make 1-hour appointments available on a same or next day basis. Also, DPC physicians generally have smaller patient panels (on the order of 500-600.) Thus, the main thing that has changed is the number of patients a physician cares for and the amount of time spent with them.

With time, a DPC physician can expect to see a practice that differs in the following ways from a practice inside the traditional FFS system:

Deeper, more intimate, and meaningful relationships

Time to dig into and research difficult medical cases, and thus provide a wider spectrum of care and make fewer costly, inconvenient specialty referrals

Time to do more procedures that were formerly referred in the interest of clinic efficiency

Wider spectrum of care due to more time available to give patients (for instance, a family doctor may provide more mental health support and rely less on counselors or psych referrals)

Time to do more thorough patient examinations and education

Time to develop and devote to alternative methods of patient care (phone, e-mail, text, video calls internet education articles, etc.)

Time to devote to continuing education to expand your scope of practice more fully to provide better value

This list of highlights (and many more) are why so many DPC doctors love their jobs!

You’re about to hire someone -- maybe for the first time! Here are the first steps. If you’ve already hired and are looking for more nuanced articles relating to managing benefits, expectations, and/or firing an employee, see elsewhere in the database

Start with a job description. What do you need staff to do? What responsibilities will this employee have? The description lays out the basics like expectations, professionalism, dress, pay, hours, vacation, benefits -- and more. Remember that the more highly skilled the position hiring for, the more diligent and detailed you should be. Hiring front desk staff is crucial, but also essentially an unskilled position. As such you have a much larger pool of applicants. Vs hiring a new provider … this pool of applicants is much smaller and can be much more tricky.

• Determine the lowest level of training a person would need to fulfill that job.
• Determine the amount you can afford to spend; budget. This also will affect your pool of applicants. Especially the more skilled ones like new providers.

Create a job posting. There are many vendors available to list your job, each of which has a different price point:

• Indeed
• LinkedIn
• ZipRecruiter
• Craigslist
• Community message boards
• Word of mouth (Broadcast on social! Share over networking!)
• Word of mouth may also be the best because it’s easier to check references if you get them from people you know

Interview. Design interview questions (example questions found here) that are meaningful to you and your practice. Consider any/all of the following modalities of interview:

• Telephone: quick!
• Videoconference: an easy way to screen for tech-savviness
• In-person: more logistics and time-intensive, but can also be more revealing. Once again the more complex the position you’re hiring for the more in-depth your interviewing should be

Call references. Again, prepare for this with specific questions in mind. Expect that you can spend up to a week (sometimes indefinitely!) chasing down references.

Background checks. A quick online search will give you a few vendors to choose from.

Contract or no? There are different schools of thought; consult your attorney and accountant for guidance.

Consider ways to avoid a bad hire (and avoid paying costly unemployment):

• Clearly define a standard trial period of X days; if the hire is not a good fit, you can “not renew” their employment. Make X be a not insignificant amount of time. 2 weeks is NOT long enough. 2 or 3 months would not be unusual
• Consider a “trial day” or “trial week” to see if you’re a good fit -- and pay them for their time without a guarantee for future employment.

Remember OSHA! A good brief from DPC Frontier here and the federal government here.

Most of us would suggest that finding a “fit” for your practice is more important than finding the candidate with the most skills or training. To a large extent, you can always train unskilled staff in how you want them to do their job. What you can’t do well is change someone’s personality. So if they aren’t friendly or hospitable or patient or tough or fierce or passionate or whatever is important to you, your practice, and your milieu … DON’T hire that one.

As someone once said: hire slow, fire fast. Good luck!

One place where primary care physicians commonly feel unprepared for is fracture management. However, many routine fractures are easily and safely treated by the PCP, and at substantial savings to the patient. Increasing your comfort with basic fracture management is an easy way to greatly increase the value you offer your patients.

Step One, Resources:

The first resource most family physicians recommend is the book Fracture Management in Primary Care by Eiff and Hatch. This is an invaluable resource, because it not only does a great job of reviewing all common fractures, dislocations, etc, but it helps the physician decide when the injury is appropriate to treat in the PCP environment, and when a referral is indicated. When PCP treatment is indicated, the book details the proper treatment, follow-up frequency, imaging frequency, etc. The second important resource is a good referral base. It is advantageous to have a local/regional orthopedist with whom you are on a first-name basis and have on speed dial. In a tough ortho case, it’s easy to snap a pic of the x-ray, text it to Ortho and ask for advice.

Step Two, Education:

If you need refreshers, go to an ortho refresher/casting/splinting workshop, etc. Or again, befriend an ortho and spend a couple of days in their clinic and have them teach you some stuff. Be creative. Ultimately, the physician will need to get out of his or her comfort zone to some extent if they’re not comfortable with ortho, and soon it won’t be scary.

Step Three: Equipment:

You’ll need casting, splinting, and bracing equipment. There are lots of options here, some are just physician preference. Here is a brief summary of equipment worth having:

• Casting material
  • Fiberglass cast rolls (generally 2”, 4” and 6” widths) (Some docs like OsteoFX roll-on casting material--handy but more expensive)
  • Cotton roll cast padding (alternative option: Waterproof cast padding-more expensive but often very handy)
  • Stockinette (also some various sizes)
• Splinting material
  • Padding/splinting combined pre-made splint products: OrthoGlass vs Plaster/foam
  • ACE bandages (2”, 4” 6”)
• Finger traps (for setting very common Colles fractures)
• Arm Slings (S, M, L)
• Cast saw (don’t buy a medical cast saw, you can get a reciprocating “multi-tool” saw and half-round blade from a hardware store--same thing, and more than $1,000 less!)
• Braces (wrist braces, aluminum-foam braces, finger braces, mallet finger brace, etc)

All of the materials mentioned are discussed in books such as Pfennniger and Fowler’s Procedures for Primary Care and there are certainly a lot of different options for casting/splinting materials. As always, it is a great idea to have a mentor who is practicing the skills you wish to develop, which can be arranged with ease in the DPC community through online social media and DPCA mentoring/discussion channels, etc. We all want to help!

If you have meetings set up with employers, how do you know if they are really ready for the power of DPC?

• The first time you meet with an employer, you must assess how serious they are about working with a DPC clinic. Are the decision-makers in the room for the meeting? Who decides on changing insurance and health care plans? Is the business owner or CEO or CFO at the table?
• Some other thoughts to consider.
• Are they looking for a new benefits advisor or willing to change advisors? Many times this is important because the person they have always used is going to want to do things the way they have always done them.
• Are they really considering what is best for employees and not just the bottom line? Finding what the employer’s main motivation is is important. Some will be all about the economics of DPC. Some really do care about their people. Some just want something that will make the employees happier.
• Have they already done their homework about new types of insurance plans? You may want to ask the preliminary question, “What do you know about DPC?” This can give you a starting point for the conversation.
• Is there a top-down approach, i.e. is the CEO or owner onboard or involved? Certainly, sometimes you have to start conversations without these people in the room just to get in the company door. Ultimately these people need to be present because they are the decision-makers.
• What is their time frame? Next open enrollment or in a few years?
• What are their baseline expectations of direct primary care? What should their expectations be for your specific DPC clinic?

Employers that have done their homework and are serious contenders will have well-thought-out answers here. If they aren’t there yet -- be patient. It takes time to turn a huge ship around.

Money is perhaps the number one consideration after your why that will ensure your DPC success. Prior to giving notice and quitting your present job, you must have a very strong grasp of your personal and professional financial situation. 

There are innumerable tools to help with financial planning, and a brief online search will open a world of financial self-help for you to explore.

At the least, you should consider addressing the following:

• Figure out your home budget. Or -- taking a step back -- look back at several months’ worth of spending and income. Where is your money going?
• Get your debt under control. Refinance, consolidate, and pay off credit cards.
• Come up with a plan to stop adding to your debt.
• Think about what financial resources you have: a benefactor? Access to free office space? A DPC doctor near you looking to partner? A spouse who has a stable income?
• Sell what you don’t need: switch neighborhoods, change schools, sell a car. What can you change to have more money available to you?
• Make it rain while you can: there are a lot of jobs in medicine that are temporary and pay well. These jobs might be a tool to help you create a more secure financial foundation. Review this Member Only article for more about Moonlighting and Side Hustles options.

The general saying for new small businesses is to plan for minimal to no profit for at least three years. This has not necessarily been the case for DPC startups, but in terms of managing money, if you chose to leave an employed position with a secure income and open your own practice, you need to plan for a dramatically different financial future. Stop spending; start saving now!

When starting your business, you’ll need to make sure to know what falls under federal versus state regulations in running your DPC practice. 

FEDERAL CONSIDERATIONS

Medicare and opt-out issues fall under federal regulation. The rules for opt-out or billing Medicare are the same across the country. 

OSHA is federally regulated. One thing to note is that if you are a solo micro practice with no employees, you do not have to comply with any OSHA standards. OSHA

All relevant federal healthcare laws still apply to DPC.

STATE REGULATIONS

1. Medicaid regulations are state-specific and you will need to find the rules for seeing Medicaid patients under your state laws. There are a handful of states that have an application for “referring and ordering status only,” which makes caring for Medicaid patients a bit easier. As part of the ACA, if you do not actively enroll with Medicaid, you are usually not able to order tests or imaging studies or refer patients to specialists. Despite this, some states are a little more lenient regarding this while others completely ban Medicaid patients from privately contracting with physicians. You should contact your state for their specific regulations before you start seeing Medicaid patients. Check out DPC Frontier for more information on Medicaid.
2. Many states have DPC-specific legislation that protects DPC practices from being treated and governed as insurance. For a list of the laws in your state, see DPC Frontier’s State-by-State guide.
3. Dispensing laws also differ by state, and while most states allow for physician in-office dispensing, several states do not allow dispensing. There are many different types of laws regarding how you dispense, whether you need a permit or need to register, and who is allowed to dispense (MD/DO vs. all providers). DPC Frontier has guidance on dispensing medications here.

Laws vary by state. As of 2021, 19 states have “direct billing laws,” 8 states have anti-mark up laws, and 16 states have disclosure laws. “Direct billing” means that the lab is required to directly bill the patient and may not bill the primary care physician (which would be “client billing”). Unfortunately, this often means that the patient receives an inflated bill. In states with disclosure laws, you must alert patients, either on your website or on your billing, that your wholesale costs are available to them upon request. Read more on pathology services on DPC Frontier.

1) How long does it take to open a DPC practice?

As the saying goes, “If you’ve seen one DPC, you’ve seen one DPC.” There are so many variables that influence this timeline. If a doctor is starting out her DPC only making housecalls, she only needs to set up the legal end of the business and dust off her doctor bag. Theoretically such a practice could open in a month. If a doctor decides to build a 3,000 square foot clinic from the ground up, hire staff, etc. it could take a year or two. Obviously, the average would fall somewhere in between. Many docs begin planning their DPC while still working inside the system in their free time, so the process can get a bit protracted. Conversely, some docs have given 3 months notice at their employed position, and the thought of having zero income in 90 days is highly motivational to get everything done!

2) How do you estimate costs and a break even point?

This is relatively basic math. Do your homework to discern what your expenses will be. Add up your monthly expenses. Divide that by your monthly fee (if you know what your fee will be and it’s inflexible) which will tell you how many patients will break you even. Or divide it by the number of patients you’re willing to take (if it’s inflexible) and that will tell you what your monthly fee needs to be to break even.

3) How do you know you are ready to open your doors?

Nobody’s ever perfectly ready! There’s always something else to get ready, there’s always something you forgot, and there’s always something you have yet to learn. Do the basics. Read all you can. Get a mentor. Then go for it. You will learn/change/grow in so many ways as you go. Sometimes you really have to just go for it. Within reason, of course you shouldn’t fail to do as much homework as you can before you start. The fact that you’re here reading this means you’re doing exactly that!

4) How do you advertise/find patients for your practice?

This is widely variable among DPC practices. The most common thread in the DPC community –by far– is word of mouth. DPC doctors give a level of care, access, and quality that so starkly contrasts with what patients are used to inside the system, that patients can’t help but tell others. Many DPC physicians maintain an advertising budget of $0 because of the success of word of mouth. That being said, in some markets, it’s more difficult to build even that initial small panel of patients who then become your word of mouth advertisers, so advertising/marketing campaigns will help get things started. These doctors have used a variety of advertising strategies, including Radio, TV, Newspaper, etc. In-general, the most effective strategy (which is time-intensive) is pounding the pavement to talk to groups like chamber of commerce, Business Networking International, going around to clubs, church groups, etc. The mantra for this is “If you’re bored, you’re doing it wrong.” The most cost-effective seems to be social media advertising, which might be lower-yield, but can be low-cost.

5) How do you outfit your office on a low budget?

It’s definitely important to keep your overhead down in DPC, and that can be hard to do, because in the medical world, prices are artificially inflated. DPC docs have numerous “hacks” for keeping overhead down, which include finding used equipment from clinics that are closing, using craigslist, auctions, getting used autoclaves from tattoo parlors, you name it. In-general, don’t buy new equipment, because medical equipment depreciation is massive and you can get “like-new” and hospital surplus equipment for a fraction of the price of new–often free. Check out this LINK for tips on keeping overhead down.

6) If you are transitioning, how many patients should you expect to follow you?

Most DPC docs will tell you that about 10-15% of your patients will follow you, and you can’t predict which ones they will be.

5) How do you outfit your office on a low budget?

It’s definitely important to keep your overhead down in DPC, and that can be hard to do, because in the medical world, prices are artificially inflated. DPC docs have numerous “hacks” for keeping overhead down, which include finding used equipment from clinics that are closing, using craigslist, auctions, getting used autoclaves from tattoo parlors, you name it. In-general, don’t buy new equipment, because medical equipment depreciation is massive and you can get “like-new” and hospital surplus equipment for a fraction of the price of new–often free. Check out this LINK for tips on keeping overhead down.

7) How do you determine pricing structure?

Most DPC docs start off by looking at how other comparable DPC clinics (in comparable areas, comparable services, etc.) set prices, and start there. Three other variables are relevant here, which are the following questions: 1) How much money do you need to make? 2) How much do you want to make? 3) How much money will patients pay you? The latter is the most important of course, and if patients in your market won’t pay enough to generate the amount you need, or you’re unwilling to accept the amount you need in place of what you want, then you’ll have to evaluate how big of a panel you can handle.

8) How do you set up labs, imaging, and a referral network?

One way to quickly get this kind of stuff is to join up with other regional DPC doctors who may have already negotiated great deals with imaging centers, labs, etc. Sometimes your EMR vendor might have similar relationships with labs for discounted rates. Or, do the groundwork yourself. Make a meeting with the imaging center owners, the regional Quest or Labcorp office, and build a cash-only price list with vendors for your patients, from the ground up.

9) How does a micropractice handle patient messages during office hours (when you are with another patient)?

Get your patients used to asynchronous communication as much as possible (e-mail and text). If they realize you reply to texts/emails way sooner than answering voicemail, they’ll use what gets them the most prompt reply. If you want it to, your practice will grow to the point where you really will need help if you wish to maximize your efficiency, and paying somebody who can answer the phone and do basic family medicine triage will be a worthwhile investment.

10) What are the biggest obstacles to success in a DPC?

Motivation and work ethic are paramount. DPC is a career-saving model for most doctors in the community, but should not be considered “easy”. You’re still a doctor and that’s never been an easy career. Doctors who set overly-strict boundaries will often fail to grow due to a poor value proposition. The flip side of that coin can be equally problematic; if a doctor sets zero boundaries, their patients may abuse them and burn them out. Another obstacle might be finances. Like any new business, a DPC practice takes time to grow and become profitable. If a doctor expects to make a ton of money and isn’t willing/able to change lifestyle while building the business, they may find themselves doing too much moonlighting, or getting deep in debt.

11) How much staff does a DPC doctor need?

Staff needs are highly dependent on practice size, and services. Some DPC docs start off as a solo micropractice, and slowly add staff as they need help. Others start with a nurse on day one, and then add additional staff. An average mature single-doctor, full-panel DPC practice would usually average 1 to 1.5 employees. Likewise, a larger practice with 3 full-panel full time docs might have 5 people on staff. Full-time staff that DPC doctors employ as they grow usually include nurses, medical assistants, and a business manager. Part time/contract labor that some DPC doctors might use might eventually include housekeepers, pharmacy techs, medical assistants, accountants, lawyers, etc. Some DPC doctors also use part-time virtual assistants as well.

12) What does DPC work day and work week look like?

This is highly dependent on the preferences of the physician and needs/preferences of patients. Most DPC docs work a stereotypical 9-5 M-F work week. When ramping up, it’s not uncommon for doctors to do “top-down” scheduling and take off in the afternoon, etc. Hours get longer as the practice grows. Many docs will take a day off every week or a half day off, etc. if it works for their practice size and doesn’t overly-restrict access for patients. Ultimately, a DPC doc can make their own schedule, as long as they stay within the boundaries of what patients consider to still be a good value for their money.

13) How do you fund your retirement accounts as a solo DPC doctor?

Speak with your financial advisor about this. There are plenty of options to self-fund IRA’s etc. You don’t have to work for somebody else to contribute to retirement accounts.

14) Where can a doctor find more information?

The DPC Alliance maintains the Direct Primary Care University, an online knowledge database. Some of the information there is free to anyone, and much of it is premium content available only to DPCA members. We encourage you to join the Alliance to take advantage of all the benefits of membership, including access to the complete knowledge database. Visit the DPC University