Keeping Overhead Low in your Direct Care Practice

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:

• Staff: I know, I know, you can’t understand how but I will share the many administrative hacks on this journey.
• Fancy Office: I swear, patients want a doctor they like (get along with, solid practice of medicine, accessible) and don’t actually care what your countertops are made of!
• Pharmacy Inventory: I can hear my DPC colleagues cringing - but hear me out!  You can (if your state allows it) dispense wholesale meds at cost to patients without any inventory in stock. 
• Expensive Electronic Medical Record: Our EMR was free and is now $100/mo for each physician.  It includes fax integration, patient portal, and online scheduling.  
• Expensive Equipment: OK, OK, you need some.  But what do YOU really need to be a doctor?  Stethoscope - check, BP cuff - check, pulse ox - check.  In primary care, the list is small.  Specialists like dermatology and surgical sub-specialities might have to increase their overhead on this front; but in general picking what you NEED and starting small, allows future growth where you see fit.
• Consulting Firm: no matter what anyone tells you, YOU can do this.  Don’t pay any non-doctor to tell you how to doctor.  If you aren’t a business person (or don’t want to be - I am not and have just figured it out as I go!), consider joining an existing DPC or reaching out to DPC doctors who have lots of experience already. 

What you do need to start is simple:

• Yourself: check.
• Your practice name: finding a friend, colleague or partner to help brainstorm your mission and dream, can help identify a great name.  A logo goes a long way too and lots of websites are up and running to help you access designers who will bid on your work at low costs (or like me, ask your BFMD Hubby to make one because he’s wicked creative!).
• Your license and malpractice - check.
• Medical & Office Equipment: your average PCP needs a few items depending on what you plan to include.  As family doctors our startup list of equipment might be a bit longer than an internist (think childhood vaccines, a table with stirrups and PAP equipment, skin biopsy supplies).  But the list is not enormous and there are great hacks for finding equipment at lower costs.
• Website: many free sites allow you to start and maintain for free or very little cost.  Searching for site names that are included or cheap, is a great way to help pick your name. 
• Fax & EMR: electronic options abound in the fax & EMR worlds these days.  Unburdening yourself from handcuff Fee-For-Service (FFS) medicine is one thing.  But I urge you to unburden yourself from being in any one physical location ever.  Use technology - faxing from anywhere is a huge key to this.  I would also argue EMR is not for everyone, and outside of insurance-based billing, paper is still allowed.
• Paperwork: you need a few forms up and running for patient sign up.

What you might need:

• Physical space: while most practices start with space, there are quite a few hacks around this.  My best advice is start small and don’t commit too long. Consider subletting or a homecare/remote care option only as you build your panel and cover your expenses.
• Billing System: some practices use ACH draws from patients, others use online billers, and others have an EMR which integrates billing.  The simplest way and the cheapest way are often different.  We prefer a billing system that takes the work out of it for us, but arguments can be made for many approaches here. 
• Lawyer, Accountant, Business Licenses: starting a solo LLC is one thing; joining with a partner to form an S-Corp or purchase property under an additional LLC is another.  We swear by the advice of our lawyer and accountant and pay them like our patients pay us.  We value advice.  
• CLIA Certificate: if you will be doing any in-house labs (i.e. urine dips, strep tests, etc) you have to get a CLIA waiver.  This is simple and affordable and adds value for patients when you include these services in your practice.
• Lab Equipment: if you want to draw, run, spin, etc your own labs, just talk to a national or local lab and this expense will be covered for you on their behalf! 
• Vaccine Equipment: a much larger discussion takes place depending on which state you’re in.  For now, suffice it to say, if this is something you’re interested, it is very state dependent and checking with your local DPCs may help delineate your options.

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...