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The DPC Startup Handbook

This handbook is the most comprehensive single resource for any aspiring direct primary care physician. It walks you though the process of starting your practice step-by-step, with detailed instructions, links to other resources, plenty of sample documents, and practical advice gathered from dozens of successful DPC practices.

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Familiarize yourself with these resources for aspiring DPC docs

DPC Frontier

This is the largest aggregation of resources for aspiring DPC doctors. There are guides to DPC-relevant state and federal regulations, information on how to start a practice, compilations of conference recordings, a list of upcoming events, a fascinating blog, and the DPC Mapper. Spend some time clicking around.

DPC Conferences

There are three main DPC conferences each year.

DPC Nuts and Bolts — put on by the Docs 4 Patient Care Foundation
DPC Summit — put on by the AAFP, FMEC, and ACOFP
Hint Summit — put on by the patient billing company Hint

Consider attending one - being surrounded by other doctors who've already made the leap is invaluable. All three conferences are at least partially geared towards aspiring docs who are either trying to decide whether to do DPC or in very early planning stages.

DPC Nation

DPC Nation is a patient-centric site focused on educating patients about DPC. Reading through it can help you teach patients about DPC in an accessible way.

Facebook Groups

There are various Facebook groups for DPC practitioners. For some, you'll need to be invited by a current DPC doctor.

DPC Alliance

The DPC Alliance formed in 2018 as a national advocacy and support organization. They have a limited list of resources at https://dpcalliance.org/resources.

Regional DPC alliances

Your area may contain a regional alliance. Google around for a website or Facebook group. Reach out to other DPCs in the area. Often they'll be more than willing to show you around their offices and discuss their workflows.

Docs 4 Patient Care Foundation

The D4PCF puts on the largest annual DPC conference, runs a direct-care-focused radio show, and have an email newsletter that's worth checking out.

Doug Farrago's Guide

Longtime DPC doctor Doug Farrago wrote an book called The Official Guide to Starting Your Own Direct Primary Care Practice. Find it on Amazon here.

Viability

Make sure your DPC practice is feasible

Consider working as an employed DPC physician

DPC is at the point where many early practices are looking to grow to multiple physicians. If you're not cut out to run a small business, consider working as an employed physician in a DPC practice near you. You'll still get all the benefits of DPC (small patient panel, less administrative BS, etc) without the headaches of starting your own practice.

Check out DPC Frontier's Careers page or iamdirectcare.com to find job listings from existing DPC clinics. Or reach out directly to the DPC practices in your area (find them with the DPC Frontier mapper).

Check if there are any legal hurdles to DPC practices in your state

This information has been compiled on DPC Frontier here.

Do you have a means of acquiring patients initially?

Are you known in your community? Are you migrating an existing non-DPC practice? Or if you're starting from scratch, can you take some patients with you?

Needless to say, a way this isn't absolutely necessary, but it will makes things easier on you (financially and psychologically).

A note on non-compete clauses: they are difficult to enforce in many states (source) so don't be too intimidated. Check out the appendices of this guide to see your state's statutes on physican non-competes. Also, don't be afraid to simply ask your employer to waive the non-compete clause.

If considering a transition, run the idea by your patients

Direct them to to learn more or use this survey from iwantdirectcare.org as a reference for the conversation.

Are you likeable?

Sounds silly, but this can make or break a practice, especially in DPC. Most DPC practices rely heavily on word-of-mouth evangelism. Any new patient has to be convinced both of the DPC model and of you. So smile 🤗

Initial Decisions

Make some initial decisions about your practice

Pick a business name for your practice

Note that your legal business name doesn't have to be related whatsoever to your public-facing marketing name! Choose a business name quickly and don't drag your feet. You want to incorporate as fast as possible so you can start engaging with vendors as a legal entity.

Google around for your state's online tool for checking name availability.

Pick a marketing name for your practice

If you're very well known in the community, you may want to include your name in the practice name for marketing reasons. If you plan to hire additional physicians or take on partners at some point, you probably don't. Click around on the DPC Frontier Mapper for ideas.

Some other considerations: make sure there are memorable social media usernames/handles available. Use a service like namecheckr.com to check availability for a name across all social media sites at once. You'll also want to make sure a decent domain name is available. Use Google Domains to check availability.

Decide on your business hours

Consider whether to have posted business hours at all. - if you only intend to be available on request, you may not want to commit to a pre-specified workday (though if you intend to have front-office staff, you probably should for their sake).

Decide whether to give your practice a specialist "flavor"

Some DPC practices have a bent towards a particular specialty/population, including pediatrics, geriatrics, sports medicine, PT, addiction medicine, pain management, endocrinology, wellness/nutrition, and more. Consider doing something similar if you're more specialized.

Decide whether to run a "pure" or "hybrid" practice

There are many shades of "purity" among DPC practices.

Some hybrid practices still accept insurance from a subset of their patients, or for certain non-included procedures. This is common for practices that are transitioning from a traditional practice to DPC. This discussion is laid out in more detail by DPC Frontier here. Also note that billing any insurance company unquestionably makes you a “covered entity” under HIPAA. A pure DPC practice may not be.

It is technically possible to run a DPC practice AND bill Medicare for certain procedures, if the benefits of practice membership explicity include only "non-covered services" (listed here), though that is highly restrictive. See DPC Frontier's analysis here.

Also note that billing any insurance company unquestionably makes you a “covered entity” under HIPAA. A pure DPC practice may not be.

Pricing

Consider your fees and markups

Choose membership prices

There are lots of options: flat rate, age tiers, couple/family plans, annual discounts, or some combination thereof. Some practices charge a one-time enrollment fee. Others have no initial fee but charge for re-enrollment. Some practices charge a low per-office visit (something that my be required depending on your state regulations).

Some practices also do access/quality tiering: for instance, a Premium plan that includes guaranteed same-day scheduling, more comprehensive preventative testing, home visits, increased personalization, etc. This is an effective way to do some price discrimimation: if there is a wealthy subpopulation in your area that's willing to pay extra for preventative care, let them! For an example of a practice that offers a low-price DPC membership and a premier concierge offering, check out Family First Health Center. However, you should make it clear in your marketing materials that your members are paying for care, not access — otherwise, you could be classified as an insurance plan by a zealous insurance commissioner.

Click around the DPC Frontier mapper to see what other people are doing.

Decide on a re-enrollment policy

It may take some time to figure out what's best for your practice based on your patient panel makeup. Some docs refuse to accept back any patient who disenrolled or missed a payment. Others require back-payment of all membership fees missed during a gap in membership. Others charge a one-off re-enrollment fee. This should be at least twice your monthly fee to discourage on-again-off-again behavior.

Rx markups

If you do in-office dispensing, decide whether to mark up dispensed meds. You can mark up meds quite a bit and still offer your patients a great deal compared to the pharmacy prices. It could be a good source of additional revenue for your practice. That said, offering "wholesale prices" on drugs is often a compelling part of your sales pitch.

Lab markups

Just as for medications, it is possible to mark up the cost of lab work while still offering your patients a great deal.

For pathology services, some states have laws against price markup by physicians; see the "anti-markup" states listed here. Still more states require disclosure to patients of the actual cost charged by the lab (see "disclosure" states here). You should probably be doing this anyway for the sake of price transparency.

Per-visit fee

Some practices charge a low per-visit fee to keep visit demand manageable. If you have a problem with excessive unnecessary visits, consider this. According to DPC Frontier, this fee should be lower than your monthly fee if you wish to qualify as DPC in most states.

Consider one-time cash-pay visits for non-members

Some practices still do one-off visits with non-member patients, either for additional revenue or as a way to attract new members. During the visit, describe DPC to the patient and offer to credit the cost of the current visit towards their enrollment fee/first monthly fee. This can be a successful marketing tool.

Consider one-year contracts

Some practices do this to mitigate the headache of billing management. For larger expenses, patients are more likely to pay by check or bank transfer, which means you lose less money to credit card fees. Plus you don't have to track down patients whose card failed on a monthly basis.

Billing cycles

Consider whether to bill in advance or in arrears. Billing in arrears (at the end of a month of membership) may seem unintuitive, but it puts you on more solid legal ground. Specifically, it is an excellent thing to point to if anyone (an insurance commisioner, for instance) accuses you of being an insurance plan. Billing in arrears also helps qualify you as an eligible expense for patients paying with an HRA or FSA. Note that DPC memberships shouldn't be paid from an HSA (Health Savings Account) — see the DPC Frontier discussion here. Some docs accept payment from HSAs without retribution; this issue has yet to be litigated.

Scope of practice

Decide what services to offer to your members

Expand your mind

Not everything has to be 100% covered by a membership (though of course, you should include as much as is feasible). Many practices offer additional services—procedures, OB, physicals, preventative health screens, etc—on a cash-pay fee-for-service basis. Consider what to include in the membership, what to provide at-cost, and what to charge extra for.

As a DPC doctor, you're the linchpin of your patients' care. Watch this excellent talk by Drs. Lassey and Tomsen on expanding your scope of practice. Some services are a great way to attract patients, others can be lucrative add-ons to your practice. Consider expanding your scope to include: Consider whether you'd be willing to offer the following services:

In-office dispensing

A lot of practices do this. In-office dispensing is a great perk to offer your patients: if saves them trips to the pharmacy and a lot of money besides. Some states also require licenses, others impose limitations, and other make it nearly impossible - see DPC Frontier's state-by-state legal analysis for description.

There may be additional administrative overheads associated with buying and tracking Rx inventory, but it doesn't have to be burdensome. You can purchase pre-packaged pharmaceuticals from wholesalers like AndaMeds or Henry Schein, and re-distribute them to patients in the original packaging. If you prefer more fine grained control, you may need to purchase a pill-counter and Rx inventory tracking software.

Note that offering some of these services may raise your malpractice insurance premiums. Also, many states will require an inspection by the pharmacy board — be sure to look up your state's policy on that.

joint injections

minor procedures

For instance: vasectomies, hemorrhoid excision, abscess I&D, and cryotherapy.

casting

cosmetic procedures

OMT

vaccines

immigration/DOT physicals

stress/VO2 max testing

migraine treatments

bone density testing

body composition analysis

travel medicine

phlebotomy

It's often worth putting in the time to learn phlebotomy, especially if you're starting off as a one-person operation. Look for classes at local community colleges or ask a nurse to teach you. This will save your patients a ton of time waiting around in a lab.

CPAP/sleep testing

coordination of hospital care

Patients will be eternally grateful to have someone truly in their corner during a medical emergency. If you want to do this, you should start researching the credentialing processes at nearby hospitals.

obstetrics

Yes, some DPC practices do this!

Incorporation

Choose the right entity structure for your practice

Determine what business structure is best for your needs

First, check out your state's guidelines on professional entities. Some states require you to operate as a professional entity (PLLC or PC) instead of a generic equivalent (LLC or Corporation). Here's a state-by-state rundown.

After figuring that out, decide whether an LLC or Corporation is right for you. Basic rule of thumb: if you want to add an additional physician/partner at some point a PC will be easier. If you know you'll stay a one-doc shop forever, a PLLC could make your life easier since it allows pass-through taxation. Basically all business revenue "passes through" the LLC to you and is treated by the IRS as personal income. This eliminates the need to do an independent corporate income tax return.

You may likely want to confer with an accountant to make this decision, or look at other nearby practices.

Draft Articles of Organization/Incorporation

This document serves to create a legal entity and provide basic information about it.

Here is a sample Articles of Organization for an LLC.

Here is a sample Articles of Incorporation for an generic corporation.

Draft an operating agreement/bylaws for the company

This document details the members' business interests and ownership shares, their rights and responsbilities as members, the allocation of profits and losses, and other protocols for managing and operating the business.

Here is a sample Operating Agreement for an LLC.

Here are some sample bylaws for an generic corporation.

When actually drafting this agreement, you and all partners of the practice should meet with a small business lawyer.

Find a registered agent

The role of a registered agent is explained in this video. It's almost always a good idea.

Incorporate the business through your state

This can usually be done online through your states business center - just Google "[state] business entity formation". You'll need your Articles of Incorporation/Organization.

File a DBA with your state

Unless you want to have "Awesome Direct Primary Care, PLLC" as your patient-facing brand, you should file a DBA (Doing Business As) form with your state. This allows you to legally operate under a different name ("Awesome DPC"). This form may also be called a Fictitious Business Name (FBN) form in some states. Google "how to file dba [your state]" for instructions.

Apply for your Employer Identification Number (EIN)

The EIN is like the Social Security number for your business. It's the number the IRS uses to identify you. You can apply for one online here - it's painless.

Forms

All the forms and contracts you'll need to run your practice

Patient Agreement

Visit the websites of practices in your area (find them using the DPC Frontier Mapper). Some have a link to their Patient Agreements linked at the bottom of their websites. See some examples fromVintage DPC, Hampton DPC, and Inspire Health.

Release of Records form

See sample here.

Billing Authorization form

If you're accepting patient billing information on paper, you'll need an authorization form. If patients provide billing information online via your billing vendor, this won't be necessary. See a sample credit/debit authorization form and a sample ACH form here.

Patient History form

See sample here.

If hiring: Employee Contract

Optionally, run everything by a lawyer

There are some very good sample documents available for free online or on the websites of established DPC practices. If you want to be 100% sure that your documents are airtight, run them by a lawyer familiar with medical law/regulation, or DPC in particular. Many practices use Luanne Leeds who specializes in helping DPC practices.

Business

DPC is for closers

Draft a business plan

Estimate initial upfront costs: including location renovation costs, equipment and materials, lawyer/accountant fees.

Estimate operating costs: rent, utilities, payroll, non-durables, lab kits, Rx.

Estimate revenues: your number of patients over time, and set revenue goals per month.

Using this information, determine how much money you must spend before you break even.

If you need a loan: do your research

Check out this // href="https://www.doctorloanusa.com/14-things-to-know-about-physician-loans/" comprehensive review of physician loans.

Consider completing a small business workshop

Check your local college for cheap courses or search for an online course. Sometimes a certificate of completion will convince a bank to give you better rates on loans.

Administration and Logistics

Set up accounting workflow

Quickbooks, Freshbooks, and Zoho are a few good options. Keeping track of all business expenses from the get-go will make life easier down the road. Make an effort to only buy things with your business credit/debit card, not a personal card.

Hiring

It easier than ever to post a job online and start hearing from candidates. Indeed and ZipRecruiter are easy to use and have a high success rate.

If you have employees: set up payroll

Gusto is excellent for this. A couple other options are Zenefits and Quickbooks. Any of these will make it easy to add new employees, set compensation schedules, and generate required tax documents when the time comes.

Open a checking account for your business

You'll likely need your business's EIN and Articles of Incorporation/Organization. For an LLC, some banks may also require a copy of your Operating Agreement.

Apply for a business credit card

It's sometimes useful to have a line of credit available early on when your cash flow is minimal. It's also may be beneficial to building your business credit score if you expect to need loans at some point.

Update your contact info with everyone!

Once you've found a physicial location (see "Location") and set up your email hosting (see "Website"), tell people your new information! Update nearby hospitals and private practices, the DEA, state pharmacy board, state licensing office, city business licensing office, local labs and radiology centers, and anyone else in the medical community who knows you. You don't want referred patients or requisitioned lab results ending up at your old employer's office instead of your own.

This is also a great way to start a conversation with other doctors about DPC.

Office

Think about your ideal space

Most practices have a small dedicated space. It's okay to be small—say, just a waiting room and an exam room. Many DPCs have made that work. Others have rented spare rooms in nearby clinics or private practices, taken over a space from a local retiring doc, or even run a micro-practice out of their own home.

Decide whether to buy, rent, or lease

Find a location

Finding commercial real estate is often harder than finding residential real estate. Lots of commercial places never make it onto Trulia or Zillow. Check out sites like Crexi or Loopnet that focus on commercial listings. Or just drive around nearby strip malls and business parks looking for real estate signs.

Arrange the front office space

Check out our Office Supplies Checklist here. We'll leave the interior decoration up to you.

Figure out the front-office check-in process

You could hire a front-office person, do patient check-in yourself, or use an iPad/kiosk for check-in.

Remember, hiring employees (even one) makes you subject to OSHA (see below).

If you have employees: set up HR/payroll software

These days, it's cheap, easy, and beats arranging a bank transfer by hand every two weeks. QuickBooks is a tried-and-true option.

If you have employees: consider offering life, health, and accident insurance

And of course free DPC subscriptions!

Insurance Opt-out

Finally say bye to Medicare

Decide when to opt out of Medicare

It is possible to open your practice while remaining opted-in to Medicare. Simply don't accept any Medicare-covered patients. Instead just take their contact info and reach out to them again when you are able to opt-out.

On the other side of the coin, it's possible to moonlight as an employed physician even after opting out, though only in limited circumstances. These include positions in occupational medicine, correctional medicine, addiction medicine, and urgent care. Hospice care is also possible, but only if your position is administrative in nature. These options are outlined in greater detail here.

Complete an opt-out affidavit

Look up your state here to find a link to the proper opt-out affidavit and the address to mail it to.

Mail affidavit at the appropriate time

You'll need to know some details of the opt-out process.

For participating providers in Medicare, new "batches" of Medicare opt-outs are made active on the first day of each calendar quarter (Jan 1, Apr 1, July 1, Oct 1). The Medicare carrier must receive your opt-out affidavit 30 days prior to the stated effective date (Dec 1, Mar 1, June 1, Sept 1, respectively). So if you start the opt-out process on December 2nd, the earliest you can be officially opted out is April 1. Plan accordingly.

If you are currently non-participating (NON-PAR), your opt-out will take effect immediately upon their receipt of your opt out form. If you are still employed or moonlighting, beware! You don't want to opt out with two months left before you quit.

Send the affidavit to the proper address (listed by state here). I recommend using a method with a guaranteed delivery date and proof of delivery (such as Certified Mail, return receipt requested).

If you wish, include a letter/prepaid envelope requesting that the carrier acknowledge in writing that the opt out was properly accomplished.

Find an Advance Beneficiary Notice of Noncoverage (ABN) form online

All new patients must sign an ABN to acknowledge that you are opted out of Medicare. English and Spanish forms are available for download here.

Notify the state Medicaid program that you would like to privately contract with patients

This may require that you dis-enroll as there is no “opt out” process with Medicaid. Some states may ask you to sign up as an ordering and referring only provider. For details on this process within your home state, Google "[state] Medicaid ordering and referring enrollment".

See the full DPC Frontier dicussion on Medicaid here.

Private insurance

Often this must be done 90 days out.

See a sample contract termination letter here. Notify all patients covered by that company that you are leaving their network (sample letter here).

Vendors

Establish your sources of drugs, labs, and specialists

Join one or more group purchasing organization (GPO)

This is often the best and easiest way to get cash prices on medications, labs, and DME. In DPC, its common to join multiple. Groupsource or PedsPal can get you deals on medications and DME from Henry Schein. Healthcare Procurement Solutions gets you deals from Labcorp, Quest, McKesson, and Medline. Joining is free and can save you a lot of time negotiating with individual vendors.

If you choose to go this route, a lot of the todo items below are irrelevant. You'll be provided with low cash prices on labs from Labcorp/Quest, medications from Henry Schein, and DME from McKesson/Henry Schein.

If you're doing in-office dispensing: sign up with a wholesale medication distributor

If you join a GPO you'll likely be provided with cash pricing on medications from Henry Schein or something similar. If you don't join a GPO, sign up with Andameds or directly with Henry Schein.

If you're NOT doing in-office dispensing: help your patients save money at the pharmacy

Point them in the direction of Blink Health, GoodRX, Marley Drug, and NeedyMeds.

Establish a relationship with a lab

For lab/pathology work, many DPC docs negotiate prices (often low or wholesale ones) with national laboratories (LabCorp, Quest, Cedar, CPL, Life Line, etc). The lab then bills the DPC practice (not the patient) for their services. Some docs treat these labs as a benefit of membership and swallow the cost; others pass the cost through to the patient (potentially with a small markup). This can save your patients a lot of money.

Offering this service to your patients requires negotiating prices with labs upfront. In these discussions, demand similar prices to those already established by previous DPC docs.

Don't forget to also negotiate a blood draw fee, especially if you don't do draws in-office. The default fee is often high ($20) but they'll typically come down to a few bucks if you insist.

There may be legal hurdles to doing this depending on your state. For non-pathology lab services, it is illegal in New York and New Jersey (see here). For pathology services, it is illegal in many more states; see the "direct billing" states listed here.

In these states, the patient must arrange payment directly with the lab. Contact the lab to determine the best way to go about this.

Establish a relationship with an imaging center

As with labs, it is possible to negotiate low prices with imaging centers.

Establish relationships with other providers

Consider arranging prices for bariatric surgery, breast health services, digestive disease specialists, endoscopies, eye surgery, general surgery, heart and vascular specialists, kidney stone treatment, oncology specialists, orthopedic surgery, pain management, physical therapy, radiology services, sleep health centers, and spine procedures.

For your reference, price sheets for each of these categories can be found here.

eBay and Amazon

Often the lowest prices, especially more medical devices, will be on eBay and Amazon.

Website

Establish a presence on the internet

Select a domain name for your website

Use a tool like Google Domains to check availability and purchase your domain. If you use Google Domains, it'll be very easy to set up email as well (more below).

Make a website for your practice

There are a lot of ways to get a website up and running.

Build your website yourself using a website builder service like Wix, WordPress, or Squarespace. These charge a monthly fee ($10-20) and let you design your site with a drag-and-drop interface. Personally, I recommend Squarespace; it has a very clean interface and easy to make a beautiful site.
Hire a freelance programmer using Upwork or Freelancer. Typical cost is $500-1000 dollars.
You could also solicit a web design studio, which will cost more then a freelancer but deliver a well-designed and polished product. This will usually exceed a thousand dollars, but gets cheaper if you find a studio who has made similar websites in the past (like Peachy Hill).
Use DPC Spot. DPC Spot is probably the easiest to set up a website for your practice, since their templates already contain a lot of DPC-tailored content. Check out a sample site here.

Set up email hosting

This will let you receive email at an address with your new domain. Usually you can do this through whatever service you used to purchase the domain in the first place.

Google offers a business offering called GSuite that includes email hosting. The price is $5/user/month, which gets you email hosting in addition to a bunch of other Google services like Calendar, Docs, and Drive. Plus, Google will sign a BAA, so you can have HIPAA-compliant email thorugh a familiar Gmail interface.

Software

Electronic health record

The main contenders are Elation, Atlas.md, and Bagel (that's us!). We started Bagel with the goal of fixing some major limitations imposed by the other major options. Read more about what we do better here. We're still under development—but you should join our Facebook group to stay updated! We'll be posting videos of new features as we implement them and accepting feedback from the DPC community. It's a rare opportunity to shape your dream EHR software. You can join the group here.

Membership management

You'll need a way to keep track of your members, enroll new patients, and manage billing in an automated way. We do this too! Bagel is an all-on-one software for DPC, not just an EHR. We help you manage charting, patient billing, scheduling, e-prescribing, lab/rad ordering, patient communication, and more. Other options are Atlas (another all-on-one software) and Hint.

Patient communication

Having a second phone number for patients to call/text is vastly preferable to giving out your personal number. Many tools also let you route texts/calls from your "virtual number" to the device/number of your choice based on the time of day. This functionality is built into Bagel.

There's a huge diversity of tools out there, each of which offers a unique feature set and interface. Two good ones are Spruce Health and Hale, both of which offer secure messaging, phone calls, teleconferencing, and a dedicated mobile app.

If you're just looking for a second phone number to use as a "business line", check out Google Voice or RingCentral.

Inventory management service

You'll need this if you do in-office dispensing. (This is also built-in to Bagel.) There are many altneratives, most of which are surprisingly expensive: MDScripts, Flexscan, and DispensePointto name a few.

E-prescribing

Some EHRs offer this as in integrated tool — including Bagel. There are also plenty of standalone e-prescribing tools out there; MDScripts and DrFirst are popular (but can be expensive).

E-faxing

Also integrated into Bagel. Some other standalone options are HelloFax, RingCentral, MetroFax, and Doximity.

Dictation software

Use dictation to make charting easier and faster. Dragon is widely used and offers a both generic and medical-focused versions (the medical version is more expensive). Apple users can use the baked-in Siri dictation on their Macs/iDevices, though your mileage may vary.

Text expander/macros

If you prefer typing notes, you can still expedite the process with a good snipper/macro software like TextExpander or Breevy. These tools let you specify snippets (e.g. "ros") that automatically expand into a full block of text (e.g. a Review of Systems). You can also specify fillable fields inside each snippet.

Virtual assistant

Some DPC docs use a service called HelloRache to "automate" a lot of the burden of charting. This service gives you a trained virtual assistant/scribe who listens in on your patient visits via videochat and charts them in real time.

Check out these other useful services

Dropbox
store files in the cloud (HIPAA-compliant with a Dropbox Business account)

Rubicon
consult a network of specialists to quickly get answers to hard medical problems

IntakeQ
single tool to create customized web forms and let patients electronically sign documents

FollowUpThen
easily schedule email reminders for yourself - there's a lot to remember when starting a practice

Insurance

Find plans to protect you, your business, and your employees

Malpractice insurance

You might want to involve an independent broker that is familiar with direct primary care, or at least private practice in general. These quotes vary hugely state-by-state. Be sure to ask for part-time rates, since you won't be fully booked in the early days.

Worker's compensation

If you employee people, you'll possibly be required to have a workers' compensation plan in place. Check out state-by-state laws on this here.

Disability insurance

If you have employees and live in California, Hawaii, New Jersey, New York and Rhode Island, you are required to provide some form of short-term disability insurance to your employees.

Business interruption insurance

Some practices in natural-disaster-prone areas may consider getting catastrophe insurance to make up for lost revenues.

Commercial property insurance (if applicable)

Commercial auto insurance (if applicable)

CLIA

AKA how to avoid the need for CLIA compliance

Decide whether to do any in-office testing

Many commonly performed in-office labs can now be performed by the patients themselves using home testing kits. This is includes HIV, Hep C, Strep, and UTI diagnostics, as well as lipid panels, TSH, HgA1c, PSA, and Vitamin D tests. See a more complete list of offerings here.

Though home testing is an increasingly good option, these kits can be frustrating and time-consuming for patients, and home kits don't exist for all CLIA-waived tests (see full list).

To do CLIA-waived tests: file for a waiver

To get waived, fill out a CMS-116 form and submit it to your state's CLIA Agency (lookup here). Some time later, you'll receive a "remittance coupon" detailing how to pay the certificate fee.

As of 2014, the following states have additional requirements surrounding physician-office lab tests: AZ, CA, CT, DC, FL, LA, ME, MD, MA, MI, NV, NJ, OR, PA, WA, and Puerto Rico. Do a Google search to figure out what else you have to do.

Washington State residents: you should fill out this form in place of the CMS-116 and mail it to the listed address.

Consider offering physician-performed microscopy (PPM) services

PPM is the next level up from waived status. It lets you do all waived tests as well as these microscopic procedures. However, this requires compliance with multiple subparts of CLIA regulation (Patient Test Management, Quality Control, Personnel, Quality Assurance, and to some extent Proficiency Testing) and is probably not worth the trouble, especially early on.

Maintain best practices

Check out this strangely colorful document from the CDC detailing best practices for CLIA-waived facilities. How much of this you decide to implement depends mostly on your risk tolerance - any CLIA-waived facility is subject to random audits, though they are rare.

Set up a reminder to renew your waiver every two years

FollowUpThen is a great free service for scheduling email reminders.

HIPAA

If you're a pure direct primary care practice, you're probably done already 🎉

Determine if you are a covered entity under HIPAA

To answer this, check out DPC Frontier's thorough discussion of HIPAA here. If you are not covered, feel free to ignore the rest of this list.

Check for state laws regarding patient privacy

In some states they are even more stringent than HIPAA.

Complete a Security Risk Assessment

This free tool from the ONC will make this much easier.

Draft a Notice of Privacy Policies (NPP)

The HHS publishes a sample NPP that can be easily customized for your practice.

Once completed, publish the notice to your website.

Draft a Release of Records Authorization Form

HIPAA requires you to have a Release of Records Authorization form on file for any disclosure of protected health information for purposes other than treatment, payment, and health care. Here is an example.

Every time you have a patient sign one of these, make a note in an Accounting of Disclosures log such as this. You must be able to acocunt for all PHI discosures you've made should you get audited.

Draft a Patient Consent Form

Though not required by HIPAA, many practices also have a Patient Consent Form which lets the patient green-light certain forms of communication (email, text, phone calls, answering machines). It also affords your practice an extra measure of protection. Here is a sample Consent Form.

Gather and maintain proof of HIPAA compliance

This is a multi-faceted problem; full compliance involves writing a Breach Plan, a Training Plan, a Communications Plan, a Disaster Recovery Plan, and an Audit and Monitoring Plan, plus the maintenance of a detailed Policies and Procedures Manual and data governance documentation. Check out this page from the AMA for some resources to get you started. You can find a lot of the Policies and Procedures online - check out Kim Corba's DPC Manual.

Gather Business Associate Agreements

You need to get a signed Business Associate Agreement from every company/product/service that handles your patients' health info. Some notable exceptions are labs, specialists you refer to, and data "conduits" (some messaging services qualify). See a complete description here and an agreement template here.

OSHA

If you have zero employees, you're done already! 🎉

Find a biohazard/waste disposal service near you

Follow best practices when dealing with hazardous chemicals/waste

If you use common sense, you're most of the way to OSHA compliance. Use safe sharps, protective equipment, universal precautions, and clearly marked waste containers. You know the drill.

Maintain a list of hazardous chemicals in your office

Keep track of all hazardous chemicals you store in your office, and make it available to your employees. Additionally, print out Safety Data Sheets for every chemical in stock. You can find most of them for free online.

Buy a fire extinguisher and mount it on the wall

Print the OSHA poster and put it on the wall

Here's a PDF.

Put your employees through annual OSHA training

Check out Medtrainer for an easy way to do online OSHA training (and many other certifications besides).

Know how to report incidents to OSHA

Every employer is required to report any workplace incidents that result in a fatality or the hospitalization of three or more employees. You can report these online here.

With more than 10 employees: draft an emergency action plan

Any employer with more than 10 employees is required to create a written emergency action plan. See OSHA's sample plan.

With more than 10 employees: do incident reporting and logging

Any employer with more than 10 employees is required to fill out an incident report (OSHA Form 301) of all workplace illnesses/injuries, going back at least 5 years. You must ALSO add each incident your your injury/illness log (OSHA Form 300). You must log some additional information for any injury involving sharps.

You must also fill out an annual injury/illness summary form (OSHA Form 300A). All these forms are available here

Marketing

Add your practice to the DPC Frontier mapper

Go to dpcfrontier.com, click "Physician Login" at the top right, create your account, and follow the instructions on screen to create your mapper listing. Fill out as much information as possible.

Practice teaching people about DPC

This is a make-or-break skill to have as a DPC doc. Get your 30 second description of DPC down pat. Iterate on your language and pay attention to what different types of patients find compelling.

If a patient wants to learn more about DPC, direct them to DPC Nation. DPC Nation is a patient-centric DPC educational website.

Create two Google My Business (GMB) profiles

You can directly provide Google information about your business, and they'll show a special business infobox on searches by people in your area. It's easy: go to business.google.com and fill out the form. You'll need a Google account.

You should create two profiles. This is important. One profile should be for your business ("Awesome DPC"), the other should be for you as a physician ("Alex Awesomepants, MD"). This way, Google will present good information to a potential patient regardless of whether they search for you or your practice.

Once you fill out the form, Google will send you a physical postcard with a verification code on it. They do this to ensure that you are a real business with a brick-and-mortar location that can receive mail. The postcard should arrive within 14 days.

Make a Facebook Page for your practice

And, yes, you'll have to actually post things to it. Preferably interesting ones. Some ideas:

preventative health tips
pithy comments about medically-related current events
PSAs relating to common issues: tick bites, flu, etc
interesting developments in the DPC world; your patients have a stake in DPC too

Claim your profiles on online review sites

Chances are you have profiles on multiple major doctor review sites. Go claim your profiles and update your information! Your previous employer may have been managing these profiles on your behalf; if so, you'll need to contact them and ask them to unlock/unclaim your profile.

Pay attention to major sites like Yelp, Vitals, RateMDs, WebMD, and Healthgrades.

Get professional photos taken

Pay someone to come and take professional photos of you and your office! Then post them to your Google profiles, Facebook page, social media accounts, review site profiles, and website.

Brainstorm ways to get free exposure

Make a list of ways to inform your community about your existence! Marketing is a numbers game; you've got to struggle along for a while before the seeds you've planted start to bear fruit. Don't be discouraged.

Be clever and strategic! Think about where lots of people go and are! Think about what you can do to curry goodwill with important figures or widely known people in the community! Winning over one super-social connector could provide you with a permanent source of interested patients. Think about subpopulations that stand to benefit in an outsized way from DPC: the elderly, the children of the elderly, athletic groups, worried moms, uninsured students, marginalized populations, struggling employers, health nuts, [fill in the blank]. Make a list of tight-knit communities where DPC could spread like wildfire: country clubs, rotaries, bingo/poker clubs. Think of free services you could provide to get people in the door or start a conversation: flu shots, cheap blood tests. Propose an interview to local talk radio stations. Ask your patients what convinced them to join - you’ll start hearing certain phrasing over and over again. Use that phrase in your marketing.

Get a logo

Find a local graphic designer, find someone on Upwork, or commission a logo design contest on 99designs. Don't try to design your logo yourself, it'll be terrible. A great logo is well worth a few hundred bucks, even if that seems high at first blush. An amateurish logo can really hamper your legitimacy in the eyes of a patient.

Custom printed stationery and marketing materials

Printing out promotional materials is a great way to put information about your practice out into the world. You never know who will see a flyer you send home with a patient. If you meet with an interested potential patient, give them a card or a brochure - they'll be more likely to get back to you if they have a physical reminder of your conversation. Put up signs around your community, especially if you're doing an open house/Q&A or offering a pre-enrollment deal.

It's remarkably easy to design these things yourself once you have a good logo. Check out Canva—it's a slick online tool that lets you plug your logo and business information into a bunch of excellent pre-designed templates.

Flyers/brochures: make it easy for your patients to advertise on your behalf.
Business cards: make it easy for your patients to contact you; this is likely a huge factor in their decision to join a DPC practice
Big posters: ask local businesses if you can put them up in the entryway. Also buy a sandwich board on Amazon here and put one on the sidewalk outside of your building
Sign: get a big sign for the exterior of your building
Envelopes and stationery

Custom letterhead, envelopes: not vital but a nice-to-have that lends additional professionalism to your practice.

Disseminate your marketing materials

Put your cards/flyers at local gyms, day cares, YMCAs, universities, grocery stores, benefits consultants, and health establishments of any kind. Think about who in your community has the greatest need for DPC. Then try to figure out where those people go.

Ask for referrals

Go chat with urgent cares and specialists near you. Pitch them on the DPC model (and assure them it’s viable - they won’t send people to you if they don’t believe DPC will work). Often urgent cares will refer "trouble patients" to you. Reach out to Health Sharing Ministries - they often highlight DPC practices.

Check for retiring physicians nearby

If they are retiring early as an escape from bureaucratic headaches, they may be interested in working as an employed physician at your practice.

Otherwise, you might be able to convince them a) of the merits of DPC and b) to send their patients your way once they close their doors.

Network with other small business owners

Check out BNI, local Meetups, the Chamber of Commerce, Rotary, 1 Million Cups, NFIB, and Facebook Groups for local business owners.

Reach out to nearby self-insurance TPAs/brokers

The DPC model perfectly complements the high-deductible, low-premium plans a self-insurance broker is likely to be selling. These brokers could bring an entire company of patients in one fell swoop.

Reach out to Health Sharing Ministries

There are probably multiple based out of the nearest city to you. Make yourself known to them - they often highlight DPC practices.

Talk to the specialists you refer to

Specialists tend to like DPC practices: they get paid in cash immediately by an entity with a face and an email address (that would be you). They may direct patients to your practice, or at least mention the existence of DPC to any particularly disgruntled patients.

Consider paying for advertising

Print: radio, billboard, and newspaper ads. The consensus is these are poor investments.
Facebook: you can "boost" a post on your Page to get it in the timelines of people in your area. It's not very targeted; your mileage may vary. Some people have found success with boosting, but the best way to get patients from Facebook is to regularly post useful, interesting content and encourage all your patients to join.
Google Ads: it's easier than ever for small businesses to advertise on Google. You have a lot of control; you can specify exactly which search queries you'd like to show up for.

Make advertising partnerships

Partner with local gyms, YMCA, and health clubs. You can each display the other's marketing materials, send each other customers, and even offer "exclusive partnership discounts" (!)

Set up a referral program

Offer a $100 Amazon gift card to patients that refer someone to your practice.

The above content is not legal or medical advice.

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