Starting a direct primary care practice is hard, but this checklist makes it a little easier. This checklist provides a comprehensive list of instructions for starting a standard pure DPC practice. There are additional steps involved in running a hybrid (part-DPC, part-insurance-based) practice, and still more if you plan to contract with employers. We don't get into that - this list is long enough as is. If you have any suggestions whatsoever, send us a message using the form at the bottom of the page.
Familiarize yourself with these resources for aspiring DPC docs
Make sure your DPC practice is feasible
Consider working as an employed DPC physician
Starting your own practice is hard work. 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 iamdirectcare.com to find nearly 40 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
AtlasMD designed this survey to gauge your patients' interest in the DPC model.
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 🤗
Make some initial decisions about your practice
Pick a name for your practice
Decide what hours you'll be open
Decide whether to join a network or remain independent
Decide whether to run a "pure" or "hybrid" practice
Hybrid practices are those that still accept insurance from a subset of their patients. It is difficult but possible run an insurance-based practice that only charges for “non-covered services” (listed here) to avoid running afoul of Medicare regulations. See DPC Frontier's analysis here.
Also note that billing Medicare unquestionably makes you a “covered entity” under HIPAA. A pure DPC practice, if structured properly, is not subject to HIPAA.
This discussion is laid out in more detail by DPC Frontier here.
Choose a pricing structure
There are lots of options: flat rate, age tiers, family plans, discounted annual rates, or some combintion thereof.
Some practices charge a one-time enrollment fee. Others have no initial fee but charge for re-enrollment. Some practices charge a low "copay" per office visit.
Click around the DPC Frontier mapper to see what other people are doing.
Decide whether to do in-house dispensing
In-house dispensing is a great perk to offer your patients: if saves them trips to the pharmacy and a lot of money besides. Of course, there are additional administrative overheads associated with buying and tracking Rx inventory. Some states also require licenses, others impose limitations, and other make it nearly impossible - see DPC Frontier's state-by-state legal analysis for details.
If you do in-office dispensing: decide whether to mark up medications
You can mark up meds quite a bit and still offer your patients a great deal compared to the pharmacy prices. It's a good source of additional revenue for your practice.
Decide whether to markup labs
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.
It's all about the money
Draft a business plan
Estimate initial upfront costs: including renovation costs, equipment and materials, and lawyer/accountant fees.
Estimate operating costs: employees paychecks, medications, labs, rent.
Estimate 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 comprehensive review of physician loans.
Determine what business structure is best for your needs
Some options: limited liability corporation (LLC), professional LLC (PLLC), professional corporation (PC), S Corporation, C Corporation. You'll likely want to confer with an accountant to make this decision, preferably one who has worked with independent medical practices before.
Select a name for your business and check its availability
The name doesn't necessarily have to be the same as the name of your practice.
Most states have a tool on their business center website that lets you check name availability.
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.
Consider finding a registered agent
The role of a registered agent is explained in this video.
As long as you're capable of receiving mail at your practice's address, it's easy enough to be your own registered agent. But in some cases - or if you just want to play it safe - you may want to find one.
Register 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.
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.
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.
Establish malpractice insurance
You might want to involve an independent broker that is familiar with direct primary care, or at least private practice in general.
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.
Only applicable to pure (non-hybrid) DPC practices
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.
If transitioning a practice: notify your patients
Give at least 30 days notice, preferably in the form of a written letter (see this template from AtlasMD). Help any patients currently in the midst of major health issues find a new care provider, or you could be prosecuted under patient abandonment laws. Look up the laws in your state.
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. 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.
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 cover letter 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.
All the forms and contracts you'll need to run your practice
If hiring employed physicians: draft an Employee Contract
Do so in conjunction with a lawyer (see below).
Whomever you choose, be mindful of Corporate Practice of Medicine (CPOM) laws in your state; see a state-by-state breakdown here.
Run everything by a lawyer
AtlasMD recommends Luanne Leeds, who has worked with DPC docs in the past.
Get your gloves on, there's paper to push
Decide whether to buy, rent, or lease
Or work from home...it's been done.
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!
Establish your sources of drugs, labs, and specialists
Establish a relationship with a lab
For lab/pathology work, many DPC docs negotiate prices (often low or wholesale ones) with national laboratories (Cedar, CPL, LabCorp, Life Line, Quest, 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. Check out the price sheet AtlasMD negotiated with Quest.
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. Reference AtlasMD's imaging price sheet.
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.
Establish a presence on the internet
Select a domain name for your website
Use a tool like Google Domains to check availability.
Find someone to design your website, or build it yourself
There are a lot of ways to get a website up and running. As with most things, how you do this is a tradeoff between money and time. From hardest/cheapest to easiest/more expensive:
- Build your website yourself using a website builder service like Wix, WordPress, or Squarespace. These charge a monthly fee ($20-30) and let you design your site with a drag-and-drop interface. Custom features like EHR integration may be difficult.
- Hire a freelance programmer using Upwork or Freelancer. You sketch what you want the site to look like and they'll build it, after a few dozen email volleys. 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).
And then there's an amazing service called DPC Spot! It makes creating your website as easy as filling out a web form, and a nice young man named Colin will walk you through every step. It only costs a tad more than Squarespace, but your site will integrate with Atlas/Hint, have email forwarding, and load fast out of the box! Plus, it'll be search-engine optimized, secured with SSL, and look great on mobile phones.
Set up email forwarding
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.
Sign up for the services you need to run a practice
Select a patient communication service
There is a huge diversity of tools out there, each of which offers a unique feature set and interface. Two of the best are Spruce Health and Hale, both of which offer secure messaging, phone calls, and teleconferencing.
Note that Atlas can also provide you with an additional phone number for texting and calls.
Select an e-prescribing service
There are an unbelievable number of options here. See the list of SureScripts-certified e-prescription services here.
Of note: e-prescribing is integrated into Elation. Atlas provides an integrated e-faxing service for communicating with pharmacies.
If you're old-school and prefer fax, check out e-fax services like HelloFax, RingCentral, or MetroFax.
Check out these other useful services
store files in the cloud (HIPAA-compliant with a Dropbox Business account)
consult a network of specialists to quickly get answers to hard medical problems
easily schedule email reminders for yourself - there's a lot to remember when starting a practice
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.
If you're a pure DPC 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.
Covered entities only: complete a Security Risk Assessment
This free tool from the ONC will make this much easier.
Covered entities only: 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 from AtlasMD.
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.
Covered entities only: 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.
Covered entities only: 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.
Covered entities only: 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.
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.
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
If a DPC practice opens in a forest but it has no patients, has it really opened?
List your practice on Google Maps
You can do so here. Also add some high-quality photos to your listing and remember to ask your patients for Google reviews.
Brainstorm ways to get free exposure
Do you have any friends who work at the local paper? If not, cold-email the news desk anyway with a press kit about DPC, your practice, and your story (template here. Propose an interview to local talk radio stations. Offer free flu shots. Host a 5K or an open house, perhaps related to an upcoming holiday.
Get an A-frame sandwich board
Get one on Amazon here. Deisgn a large poster for it, get a laminated copy printed, and put it by the sidewalk closest to your practice. If you're near a busy street, this is equivalent to hundreds of dollars of free advertising."
Print custom stationery
Marketing flyers, price lists: 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/
Custom letterhead, envelopes: not vital but a nice-to-have that lends additional professionalism to your practice.
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. Check out this template letter published by AtlasMD.
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.
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
Consider paying for advertising
There are the old-school methods: radio, billboard, and newspaper ads. The consensus is these are poor investments.
Online advertising can be much more successful. Facebook lets you "boost" posts to your Page for $5, which displays it in the timelines of people who might be interested. Also it's easy to advertise on Google using Adwords Express.
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.