Starting up a direct care practice can be very inexpensive. With the Direct Care Lite theme in mind, I want to review how you keep costs low when marketing a brand new practice. The great news is that YOU are your best advocate. While I realize this concept may inspire fear in the hearts of many physicians who do not see themselves as marketing experts (never mind the fact that you're already worrying about being a business person and entrepreneur!), it is not that hard and yes YOU can do it!
If you start a practice from scratch, you have few or zero patients on day one and have to find a way to spread the word yourself. Of course you can hire a paid marketing support person, but in my experience they help more once you've already gotten the ball rolling. Without any patient word of mouth and without much money to fund your marketing budget, you have to strap on your boots and pound the pavement yourself.
Here are my top suggestions for self-marketing for free:
- Find all of the local online and print newspapers and email a few people you find. Look for a content editor, someone who wrote an article you like, or any name you can find. Send them your pitch - i.e. why you started such a unique practice, how it is new and there is nothing like it around, how this model is growing leaps and bounds and we finally have one here! Expect to email them many times over the course of months. Some will write something quickly and others will take time responding.
- Link every article about you on your website - Share the link via your website on facebook, instagram and in a newsletter. Organic publicity via shared social media links that lands people back on your website is worth its weight in gold!
- Use each article for the next one - send the link(s) to your site and the articles written about you to each new news source that you are hoping will write about you so they can see that you are newsworthy!
- Network, network, network - every person you meet should hear about what you're doing. Tell your kid's friends' parents at soccer, tell your church group, tell the person you run into at the coffee shop. For every person who shows any interest, get their email. Add every email you collect to your newsletter. If you're invited to a BNI group, say yes. If you have the option to go to an evening marketing event for the town, say yes. If you can attend a local chamber of commerce event, say yes! You get the point - I promise once your snowball is rolling you won't have to do this anymore :).
- Start a newsletter - as I've mentioned above this is key. It gives you one place to store every email you collect from networking and to put together the links of articles that you generate from local press to share with the email list. You should also link to any blog posts you write for your practice, share photos, make it personalized about who you are and why you are doing this as you start out.
- Have a Facebook and Instagram Presence - post as often as you can remember. Post every blog you write, every article that is published, do a "throw back thursday" and repost old articles, share photos of your day-to-day as a DPC doc, and add local events where you tag local businesses so they like and tag you back!
- Collect Google reviews - 7 years into practice we have patients all the time who join and say "your reviews are so much better than every other practice that I just had to join!" Ask every new patient in your welcome email to review you on google and/or facebook (Google is tops because it is everyone's favorite search engine and your high review will bump you higher on searches). If anyone gives you a compliment, thank them and ask them to post in a review (and feel free to explain it's the best way for other patients to find you!). Use your reviews in memes on facebook/IG and in your newsletter to share the words of others recommending you.
- Blog - use your website's blog to write about what interests you in medicine, in DPC, in your world. Make it personal and informative. Make sure to link to other articles to help with Search Engine Optimization. DPC blog examples for ideas: https://www.plumhealthdpc.com/blog,
- Recirculate - basically once you've done everything above, do it again. Cycle through these things over and over until you've gotten to a point where you can start putting some money into facebook and google ads (and/or hire someone to help with that) and/or you have patient word of mouth taking hold. Seven years in and one of the few expenses we still splurge on as we continue to grow our panel is a marketing expert, google adwords, and facebook advertising. We may be full soon and end this arrangement, but for years it has paid us back. But our first two years we did not put a dime into this and we got our own ball rolling...and you can too!
More on keeping overhead low when you startup...
More on startup cost calculations...
No two direct care practices are created equal. If you're debating how to begin your DPC, there are many blog posts that will discuss the basics of direct care, how to open a Direct Care Lite practice, and the nuts and bolts of startup costs. (There are also some amazing and inspiring podcasts to help you start your practice). If you have a game plan or are deep into your own practice (which might be months or even years in), this post is meant to help you identify the best ways to "troubleshoot" the issues you find you are having day-to-day.
Our DPC is a micropractice (think no staff) with an emphasis on simplicity and low overhead. In our case, we find
I advocate the "step-back and analyze" point of view. In other words, look ahead a few days, a few weeks on your work schedule and block out a few days entirely. (If your practice is like mine, you can spend an hour or two a day on those days handling things that arise that are urgent for patients and using the rest of your time to analyze your practice). When you are knee-deep in daily practice and seeing a full panel of patients, your efforts to make changes are unlikely to work because the urgent needs of the patients you are seeing will take over (as it should). Hence, I strongly advocate taking time off from seeing patients and doing a full review of your practice.
If you know of an issue with your practice that you want to fix, start there. If you just want to do an overview of your practice and shore up some improved procedures to save time and money then consider a more general review. When you are focusing on a single issue here are some factors to consider:
- Why is this a problem? For me or patients? And therefore, is the issue time or money related or is it simply causing unnecessary frustration?
- Time related: how can this be done using less time?
- Cost related: how can this be done with less expense?
- Frustration related: why is this bothering me or my patients and is there another way to do it?
Here are a few case studies of these concepts.
I have patients calling, texting and emailing me all day during the work day and I cannot see patients and respond to others at the same time. I want to maintain no/low staff so how do I handle this?
When you step back and look at this issue, you want to decide what is YOUR preference. Do you prefer patients text, email or call? Do you prefer to handle issues (that are clinically safe to do so) remotely or do you prefer to have patients come in for a visit? Many practices evolve to allow patients to contact you via all of these methods and each patient does not have a clear view of what the physician prefers. Managing all avenues can be overwhelming. So, this practice should pick their preference for weekdays and for after hours.
- In my practice, patients can send an after hours email for things that can be handled during work days and I will manage those in between patients during my work hours.
- Patients can text me during regular works hours or email via the private patient portal. I have scheduled a buffer of 15-30 minutes that I enter myself on my scheduler (which is part of my EMR) so that after and before patient visits I have time to handle visit-related tasks and/or respond to texts and emails.
- If a patient sends a non-urgent text after hours, I send it to myself in email form and manage it during the week. I also send a gentle reminder for repeat offenders that email over the weekend/overnight is ideal for non urgent issues so I don't lose the text by the next work day.
- When I determined these rules help me the most, I sent this to my patients in a brief email so that they could refer back to the best ways to reach me when they weren't sure!
I can't get through all this paperwork!
First of all, big step back - what paperwork? At our practice we've really eliminated paper about 98% of the time. I urge you to review what paperwork you use that is wasting your time - filling out forms, signing, scanning, shredding, filing, etc.
Examples of switches to electronic options:
- Switch your sign up forms to an online format (most patients can sign a pdf on their phones so we email a link with forms to them from our website and they email back); there are tech-savy options like DocUSign, etc but because money is money, we go the free route!
- Change your medical records request to FAX only (eliminating the address has dropped the number of paper charts we get by about 90-95%).
- Set up an electronic fax that integrates directly into your EMR so it's a one stop shop. If you have to file away prior charts, sign and send a form and then save it in the EMR, or complete paperwork and keep it on file - an e-fax/EMR connection does it all without any printing/scanning/filing/envelopes/stamps/you get the point!
- Scanning and shredding are the single most time consuming things I did early in practice - switch to electronic but if you must have paper, get a high speed scanner that can run a lot of pages at once and invest in a shredding service. We have one big bin outside the office and it gets replaced twice a year - that is the best $130 per year we spend in time-savings!
- Review your paper problems and decide where you can improve tech to save yourself time and money!
I'd love to help you brainstorm and troubleshoot so shoot me an email and I will write a blog about your problem or if it's more complex, talk to me about consulting directly to help you break your problem down and make your practice work. Remember - if the practice is not sustainable for you, then it is not going to be around to help patients, hire staff, etc so if you suffer, everyone suffers. It's not too late to make a working change!
More on the nuts and bolts of starting or improving your Direct Care practice...
When you first start your Direct Care practice you may not know the answer to questions like "how do I want patients to reach out to me?" This means you can't teach them right off the bat because you don't know how you will want to communicate. So to start, here's what I do.
When I meet with a new patient I explain that because of my family/work balance I am not always in the office but that I can be reached at any time. I emphasize that after hours for an extremely urgent issue only, calling is best so I don't miss it (but when they call they will hear a voicemail letting them know I respond to urgent voicemails back quickly but otherwise will return calls during business hours). Otherwise I tell them text or email is fine but if it's not urgent, email is the easiest way to reach me and it's their choice about using the private hipaa portal or regular/non-secure email. I explain that even though I'm not in the office 24/7 I can help handle most things remotely and help them determine when a visit might be clinically necessary.
This sets patients up with the expectations that:
(1) I am not a 24/7 Concierge Urgent Care Service of 1.
(2) They can reach me when they need me...so anxiety about getting a hold of their doctor is unnecessary :)!
(3) Emailing me is usually best unless urgent; in which case a text or call works, depending on hour of the day and their prefernce.
I then respond to almost everything I get via text or email. This allows me to review the incoming emails, texts and calls and see what IS urgent. Urgent stuff gets responded to first thing when I arrive to work (after working out of course - healthy doctor, happy doctor!). Non-urgent stuff gets handle during the day between patients when I have a window. I almost always leave 30-60 minutes before my first patient for the urgent replies and a buffer before each visit to handle anything that pops up or wasn't handled first thing. On my days at home, I try to allot 1-2 one hour slots to work on issues.
When I respond to questions, concerns, needs via email or text, then patients start to realize that is my preferred method of communication and most patients will follow suit in the future. But what about those pesky patients who really want to barrage you with emails, texts, and calls everytime they see you are starting to respond? First, anything outside of 9a-5p, does not get a response until that time on the next business day unless deemed extremely urgent. When I do respond the next day, I first emphasize that if they have something that pops into their head after hours, it would be best to email me so I see it at work the next day to help with their concern. This almost always helps prevent this next time! For those who do not get it after a few reminders, I will send an email explaining my preferences on contacts for what and how.
As you feel out your practice your preferences will solidify. But remember, the absolute key in being burden free is being sure to model your style of communication after what you like best. Many docs avoid texting because they find it hard to track. Others, like me, don't love phone calls and reserve those for visits only, with a few exceptions. Make your practice work for YOU and you can sustain it longterm for your patients!
Read about how I keep my overhead low...
If you’re considering forms, congratulations! I assume that means you’re taking the leap and now just trying to get your ducks in a row to start on-boarding new patients. The “convincing yourself and everyone around you that you’re doing the right thing phase” is over. Now you know you ARE doing the right thing to unburden YOURSELF from the system and to care better for YOUR patients.
You want to be set up with the right forms to make the on-boarding process as simple as possible for you AND patients. Many DPC practices share their forms online. Here are a few examples to look through to get your own together. I suggest reading through a few and copying and pasting the parts that make sense to you. When you have that model, go through and make sure it says what YOU want to agree with your patient about. If you feel comfortable, ask a lawyer with familiarity in the direct care world to help you review your final product.
This is between you and your patient so it needs to be tailored to what you’d like to offer in terms of services, time commitments, etc. Be careful going through it to make sure it is what you want it to be. Here are some examples: Kansas City DPC, Direct Doctors, AtlasMD. The amazingly helpful guys (aka doctors) at AtlasMD offer free services to those setting up or participating in direct care practices - one of these is legal counsel, so check them out if you have questions!
You possibly/probably need a HIPAA statement (depending on which view you accept on whether Direct Care practices qualify for HIPAA).
Medical Record Release
A couple of examples exist online of DPC records releases - i.e. AtlasMD, Direct Doctors. Copy one of these styles but remember the key in staying burden free is how do you want records to arrive? We only want faxes - why? - it keeps us burden free and paper free. We review, we send to the EMR, we are done. Paper requires scanning and shredding, both time consuming and not without costs.
Medicare Opt Out Form
If you opt out of Medicare and you see Medicare patients (remember some are disabled and younger, so ask everyone who joins!), you will need them to sign an Opt Out Agreement. The gist is, this lets them know that neither you nor they will bill medicare for your services. They can still use Medicare for everything else. Here’s a sample from AAPS.
Other forms will come up with patients as you proceed (i.e. controlled substance agreement, one-time visit agreement, and letterhead) but you will likely have time to make those as you go along. DPC Frontier has lots of form information. If you’re starting from scratch, i.e. out of residency or in a new geographic location, you will have lots of time during start up to work out these kinks. If you’re transitioning an existing practice, you may need this stuff up and running asap.
While time is money, money is also money. Loving and living in your Direct Care practice does not have to mean spending more than you earn to keep the lights on. It does not require a massive startup budget. It requires some careful planning, and maybe a good spreadsheet or two! The best advice I can give is pick and choose what you NEED and start there. You can always add wants and maybes down the line.
Here is what you don’t need to keep your practice running smoothly:
What you do need to start is simple:
What you might need:
Your practice has to be right for YOU but taking baby steps when it comes to footing the bill is the smartest way to build a simple, sustainable practice without adding new burdens to your life.
Read more about what forms you need to start your Direct Care practice...
What would you tell the elderly mom of your disabled alcoholic patient in his 30s when she is buying him alcohol - stop enabling! It's important that you stop enabling patients to take advantage of YOU. No person - no doctor - can sustain being at the beck and call of anyone, never mind a panel of patients.
In Direct Care, YOU are in control of YOUR practice. A huge benefit of the model of care is that you schedule how it works for you and you determine how you want to be contacted and seen. Patients aren't expecting medication delivered to their door; most don't want unneeded tests once you explain the data; all they really care about is access to you.
If you offer a never-ending, never-say-no, style of practice - patients believe that is what they should expect. If you're at your daughter's basketball game, and they're used to you dropping everything to do a home visit - then they expect you to drop everything to do a home visit. Most of us cannot sustain such never-ending, no-boundaries care. And we DON'T have to. If your practice can't make it because you cannot sustain what you think you have to promise to keep your patients, then your patients will soon be out one very good doctor. Most of us are in medicine because we are altruistic about caring for others and it's easier than most to fall into the trap of giving too much of ourselves.
First step to rebooting the success of your over-promised practice - decide what kind of practice do YOU want to have? If you love home visits, you have to build time for it within the work hours you prefer. If you want to see newborns at the hospital or at home, make sure you have buffers in your schedule where you can make that happen. Learning to say no to things that are not your priorities is one of the most important boundary-setting exercises.
If you find yourself knee-deep in enabling, I suggest taking that step back to look at what you are doing that you LOVE and what you are doing that is sucking the energy out of you. Make two lists and be honest with yourself! Figure out how to remove things from the "bad" list. If you find that you wish you were seeing more sports medicine for your own patients rather than referring that out and you realize you don't love doing IUDs - change the menu of services you offer. If you find you can't fit in home visits for elderly patients, charge an amount fitting to homebound care so that you can see fewer patients but at the level that they and you need.
If you find yourself lost in determining how to unburden your practice, I am happy to help! Email me at email@example.com and get on my mailing list to be updated about new blogs and calculators that can be your tools to success.
More on troubleshooting your Direct Care practice...
More on patients reaching out all the time...
No offense, but taking an employed-physician job is easy (or at least an easy way to start). Sign your contract, work your hours, collect your paycheck. Just follow their rules and meet their standards. Work with your numerous staff and focus your 7-10 minutes per patient encounter in your office on writing your note the way the insurer wants it, and coding so that you meet your RVUs. The hard part is that this fee-for-service model handcuffs you into a way of practice and drains the love of medicine out of many of us.
You are not independent. You are dependent in every sense of the word. When COVID hit, did you get furloughed or have your pay cut back? If you think you're indispensable, think again. Your one employer can cut your pay and take your job any day he or she wants. Independence comes from working for yourself and your patients - the way medicine was meant to be.
Financial Independence (F.I.) - made famous by the likes of Mister Money Mustache and Physician on FIRE informed many of my decision along my Direct Care journey. I chose independence from corporate medicine instead of signing a six-figure contract out of residency because I saw the potential independence and happiness I could achieve.
In F.I. the major motivator is savings rate - the more you save, the faster you reach your goal, and the sooner you can retire and live off of your savings. Math makes the calculation simple and cutting back your monthly expenses makes the goal achievable. Physician F.I. Bloggers, like Physician on Fire, XRAYVSN, and the Darwinian Doctor all have their own versions of F.I. But, as my journey into F.I. blogs deepened alongside my journey as a Direct Care doctor, I realized the important caveat to F.I. for my husband and I as physicians - we can (and now DO) love our work.
The best way to reignite the passion for our work has come in the form of DPC (lite). Much like F.I., our practice model focuses on keeping overhead ("monthly expenses") at a low percentage of our revenue. In F.I. the point is to minimize expenses --> to maximize savings --> to gain ultimate independence and freedom financially (rather than maximize income --> to continue along with exorbitant expenses). In Direct Care (lite) the aim is to minimize expenses to gain independence and freedom professionally.
A doctor with 600 patients, at an average of $60/member/month with a 60% overhead takes home $172,800 gross income. A doctor with 350 patients, at the same average, with a 20% overhead takes home $201,600. If you think it's not possible to keep overhead to 20% - I have a secret to share. I am that second doctor. I have 350 patients and the math is accurate. My partner and husband and I share a practice and we're at close to 1000 patients without any staff.
When you add monthly expenses (i.e. staff/benefits and overhead) to your Direct Care practice, you lose financial flexibility and you get stuck in the Fee-For-Service Conundrum all over again - more time on more patients to cover more costs to pay yourself the same. Time, control, and flexibility shrink away.
My husband, and fellow doc, wowed me with his dedication to lightweight backpacking when I met him almost 15 years ago during anatomy lab. He had recently hiked a large portion of the Appalachian trail (A.T.), a hike that runs from GA to ME, coursing over 2000 miles of terrain. He started his hike with a 60 lb pack full of all the gear he believed he required and reduced it to 8 lbs as he realized that everything he carried with him was a burden his shoulders alone could bare.
In 2014, I started my Direct Care journey with the model of lightweight backpacking and The Ideal Medical Practice as my guiding principal. Picture one guy hiking the A.T. carrying his 60 lb pack on his shoulders. He is slower, more burdened and less likely to succeed than his counterpart, skipping along with an 8 lb pack. He can switch to a side trail or move around an obstacle blocking his path with ease. He's flexible and nimble.
Direct Care, mostly in the form of Direct Primary Care, is taking the medical world by storm. More and more physicians burn out of being managed and manhandled by corporate-non-medical bosses and insurance-dictated standards. Direct Care is doctors' medicine for what ails us. A way to regain passion for medicine, connection with patients, and the satisfaction of controlling your own destiny makes this model a winning career change for many.
But, you worry about personal costs, a lack of protection, issues of loan forgiveness and a lack of support - all thanks to the golden handcuffs you've become used to wearing. Break away with your 8 lb pack. Start your Direct Care practice without these fears.
Remove the assumption that you need to spend a lot to start your practice; that you need to hire staff; that you need to take out loans; that you need to build out your office space; and that you can't work without the support of others. The smaller the burden of overhead and startup costs that you carry on your back, the less of a heavy leap it will take to make your first footsteps.
The Direct Care (lite) model - aka micropractice, aka Ideal Medical Practice, aka low overhead, aka low or no staff model of care - is simple, intentionally. The less your overhead, the quicker to pay yourself, the more pay per hour worked, and the larger the percentage of every new patient membership stays in your pocket.
The sooner you learn that patients aren't buying your expensive marketing, your fancy build out, your high-end table, or your personalized pharmacy, the sooner you realize they are paying for YOU. Access to Direct Care docs is unprecedented and unmatched in the Fee For Service world. You are valuable and you are the value proposition. All you NEED is who you are - you've already invested so much time and money into becoming Dr. YOU - now you owe it to yourself to value that as your patients already do.
Embarking upon a new path in your career is daunting. But you're not happy and you likely haven't been happy with your career's trajectory for some time. That's usually a big part of why you're exploring a change. Or maybe you're leaving residency soon and realizing the Fee For Service (FFS) world isn't all it's cut out to be.
This doesn't mean you have to reinvent who you. This means it's time to BE the doctor you've always been. Most of us choose medicine to help others and many of us have a passion for the intellectual pursuits that are inherent in good patient care. Starting a Direct Care practice does not mean you have to be anyone other than that Doctor who chose that path to begin with.
I hear from prospective and existing patients all the time about how they are disappointed when they join a practice to see a new physician and end up having all of their followups with midlevel providers. They call the office to ask their doctor a medical question, and they hear back from a medical assistant. There is an extremely high level of value inherent in YOUR degree and training. Patients see that; corporations see that; and you NEED to see that.
Many physicians leaning toward a career change into Direct Care worry they need to reinvent themselves, stretch their comfort zones, and add new services or specialties in order to be seen as offering value. Ultimately, most patients (the "best" ones for direct care) just want more access to you. In any practice, most patients love their doctor - but, what they don't love is how hard it can be to reach you and to feel heard. Allow the ACESS to YOU to be your differentiator - it's free!
If you're new to the concept, this post will review what it means to be a Direct Care practice. Most accept that the Direct Care model of medical care delivery began with Garrison Bliss MD at Qliance in Washington State while others believe pioneers like Brian Forrest MD of Access Healthcare Direct receive a lot of credit too. Regardless of the exact details of its roots, the concept has remained simple and grown exponentially.
Direct Primary Care (DPC) is the most common Direct Care practice. Rather than billing insurance like the Fee For Service model (FFS), DPC doctors bill patients directly as a monthly membership fee. This allows a predictable stream of income for the practice and gives doctors the opportunity to reduce the number of patients per physician, leading to much higher access for patients to their doctor. Most practices offer cell and email access directly to the physician. Many also offer discounts on labs, medications, and assistance in accessing more affordable imaging and specialty care.
The major goals of DPC are affordable, transparent cost for direct access and care through a physician who is not over-burdened by patient volume and insurance-dictated administrative responsibilities. Removing the burdens related to insurance billing (staff & related benefits, billers, data-miners, etc.) reduces the overhead costs required to run a practice. This is what allows doctors to have fewer patients on their panels (i.e. 300-600 rather than 1000s) and therefore spend more time per patient (including in-person, remote care, researching difficult medical concerns, etc.).
In reducing the administrative burdens faced by physicians in the FFS world, Direct Care doctors regain the control of direct care of patients, their own scheduling needs, and remove the sense that their rushing through their days checking boxes and referring patients out. If you're intrigued by the possibility of reigniting your flame for practicing medicine and patient care, I urge you to keep exploring how I've established and run my DPC in the simplest of ways.
Keep reigniting your flame for medicine:
- Be the Doctor You've Always Wanted To Be...
I am a Family Physician, wife to a doc, and mother of three with a mission to convince you as a doctor that you are worth more than the system is giving you and that you are already well-equipped to make a big change without adding more burdens! My passion is helping existing or start up Direct Care practices learn to troubleshoot, streamline, and simplify.