🚀 The DPC Startup Handbook

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 two main DPC conferences each year:

• 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.

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.

DPC Resources

A curated collection of tools, guides, and resources for Direct Primary Care physicians.

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 a book called The Official Guide to Starting Your Own Direct Primary Care Practice.

Startup DPC

A practical guide to launching your own Direct Primary Care practice, covering everything from business planning to patient acquisition.

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 to find job listings. Or reach out directly to the DPC practices in your area using the DPC 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?

A note on non-compete clauses: they are difficult to enforce in many states so don't be too intimidated. 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 DPC Nation to learn more.

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.

Do you have enough financial runway?

Most DPC practices take 6-12 months to become financially sustainable. Some take even longer. Make sure you have enough savings or alternative income to cover both your personal expenses and business costs during this ramp-up period.

Consider moonlighting, keeping a part-time position, or having a working spouse to bridge the gap. Many successful DPC doctors recommend having at least 12 months of living expenses saved before making the leap.

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. If you plan to hire additional physicians or take on partners, you probably don't. Click around on the DPC Frontier Mapper for ideas.

Make sure memorable social media usernames are available. Use namecheckr.com to check availability across all social media sites. Use Namecheap to check domain 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.

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

Some hybrid practices still accept insurance from a subset of their patients, or for certain non-included procedures. This is common for practices transitioning from traditional to DPC. See DPC Frontier's discussion here.

Note that billing any insurance company unquestionably makes you a "covered entity" under HIPAA. A pure DPC practice may not be.

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 also do access/quality tiering: for instance, a Premium plan that includes guaranteed same-day scheduling, more comprehensive preventative testing, home visits, etc. Make it clear in your marketing materials that your members are paying for care, not access.

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

Decide on a re-enrollment policy

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. Others charge a one-off re-enrollment fee (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 patients a great deal compared to pharmacy prices. That said, offering "wholesale prices" on drugs is often a compelling part of your sales pitch.

Lab markups

It is possible to mark up the cost of lab work while still offering patients a great deal. For pathology services, some states have laws against price markup by physicians.

Per-visit fee

Some practices charge a low per-visit fee to keep visit demand manageable. 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 do one-off visits with non-member patients, either for additional revenue or as a way to attract new members. Offer to credit the cost of the current visit towards their enrollment fee.

Consider one-year contracts

This can mitigate billing management headaches. For larger expenses, patients are more likely to pay by check or bank transfer, which means you lose less money to credit card fees.

Billing cycles

Consider whether to bill in advance or in arrears. Billing in arrears puts you on more solid legal ground and helps qualify you as an eligible expense for patients paying with an HRA or FSA. See DPC Frontier's discussion on Health Savings Accounts.

Expand your mind

Not everything has to be 100% covered by a membership. Many practices offer additional services 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.

Watch this excellent talk by Drs. Lassey and Tomsen on expanding your scope of practice.

In-office dispensing

A lot of practices do this. It saves patients trips to the pharmacy and money. Some states require licenses, others impose limitations. See DPC Frontier's state-by-state legal analysis.

You can purchase pre-packaged pharmaceuticals from wholesalers like AndaMeds or Henry Schein.

Consider offering additional services

Determine what business structure is best for your needs

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

Basic rule of thumb: if you want to add an additional physician/partner, a PC will be easier. If you'll stay a one-doc shop forever, a PLLC allows pass-through taxation.

Draft Articles of Organization/Incorporation

This document creates a legal entity and provides basic information about it. Sample Articles of Organization for an LLC. Sample Articles of Incorporation for a corporation.

Draft an operating agreement/bylaws

This document details members' business interests, ownership shares, rights and responsibilities, allocation of profits and losses, and protocols for managing the business.

Sample Operating Agreement for an LLC. Sample bylaws for a corporation.

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 state's 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 "Awesome Direct Primary Care, PLLC" as your patient-facing brand, file a DBA (Doing Business As) form. This may also be called a Fictitious Business Name (FBN) form.

Apply for your Employer Identification Number (EIN)

The EIN is like the Social Security number for your business. Apply online here - it's painless.

Patient Agreement

Visit the websites of practices in your area using the DPC Frontier Mapper. See examples from Inspire Health.

Release of Records form

Essential for transferring patient records between providers.

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.

Patient History form

A comprehensive intake form for new patients.

If hiring: Employee Contract

Standard employment agreement for any staff you hire.

Optionally, run everything by a lawyer

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.

Draft a business plan

• Estimate initial upfront costs: location renovation, equipment/materials, lawyer/accountant fees
• Estimate operating costs: rent, utilities, payroll, non-durables, lab kits, Rx
• Estimate revenues: number of patients over time, 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.

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.

Set up accounting workflow

Quickbooks, Freshbooks, and Zoho are good options. Keep track of all business expenses from the get-go.

Hiring

Indeed and ZipRecruiter are easy to use and have a high success rate.

If you have employees: set up payroll

Gusto is excellent. Other options are Zenefits and Quickbooks.

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 your Operating Agreement.

Apply for a business credit card

It's useful to have a line of credit available early on when cash flow is minimal. It may also help build your business credit score.

Update your contact info with everyone!

Update nearby hospitals, private practices, the DEA, state pharmacy board, state licensing office, city business licensing office, local labs, radiology centers, and anyone else in the medical community who knows you.

Consider your options

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

Decide whether to buy, rent, or lease

Each option has different implications for your cash flow and long-term plans.

Find a location

Check out sites like Crexi or Loopnet that focus on commercial listings. Or drive around nearby strip malls and business parks looking for real estate signs.

Arrange the front office space

Get the necessary office supplies and arrange your waiting room and exam areas.

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 makes you subject to OSHA.

If you have employees: set up HR/payroll software

QuickBooks is a tried-and-true option.

If you have employees: consider offering benefits

Life, health, and accident insurance - and of course free DPC subscriptions!

Decide when to opt out of Medicare

It is possible to open your practice while remaining opted-in. Simply don't accept any Medicare-covered patients initially. It's also possible to moonlight in limited circumstances (occupational medicine, correctional medicine, addiction medicine, urgent care). See more details here.

Complete an opt-out affidavit

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

Mail affidavit at the appropriate time

For participating providers: 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 affidavit 30 days prior to the stated effective date.

If non-participating (NON-PAR): Your opt-out takes effect immediately upon receipt. Be careful if still employed or moonlighting!

Use Certified Mail with return receipt requested.

Find an Advance Beneficiary Notice of Noncoverage (ABN) form

All new patients must sign an ABN to acknowledge that you are opted out of Medicare. Download forms here.

Notify state Medicaid program

This may require that you dis-enroll as there is no "opt out" process with Medicaid. See the full DPC Frontier discussion on Medicaid here.

Private insurance

Often this must be done 90 days out. Notify all patients covered by that company that you are leaving their network.

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. Groupsource or PedsPal can get you deals on medications and DME. Healthcare Procurement Solutions gets you deals from Labcorp, Quest, McKesson, and Medline.

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

If you don't join a GPO, sign up with Andameds or Henry Schein.

If NOT doing in-office dispensing: help patients save money at the pharmacy

Point them to Blink Health, GoodRX, Marley Drug, and NeedyMeds.

Establish a relationship with a lab

Many DPC docs negotiate prices with national laboratories (LabCorp, Quest, CPL, Life Line).

Don't forget to also negotiate a blood draw fee. The default is often high ($20) but they'll typically come down if you insist.

Establish a relationship with an imaging center

It is possible to negotiate low prices with imaging centers for your patients.

Establish relationships with other providers

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

eBay and Amazon

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

Select a domain name for your website

Use Namecheap to check availability and purchase your domain.

Make a website for your practice

• Build yourself using Wix, Squarespace, or Webflow ($25-80/month) - Cheapest option but requires more time and technical comfort. Good if you enjoy tinkering.
• Use DPC Spot ($80-250/month) - Best option for most DPC docs. Purpose-built templates that understand what DPC practices need. Easy to set up with less customization than a custom design.
• Hire a web design studio like Digital Silk, Hedy & Hopp, or Huge ($5k+) - Most expensive but fully custom design tailored to your brand. Worth it if you want a unique look and have the budget.

Set up email hosting

Google offers Google Workspace that includes email hosting at $7/user/month. Plus, Google will sign a BAA, so you can have HIPAA-compliant email through a familiar Gmail interface.

Electronic health record

The main contenders are Atlas.md, Hint, and Elation. Research which EHR best fits your workflow and needs.

Membership management

You'll need a way to keep track of members, enroll new patients, and manage billing. Options include Atlas.md (all-in-one) and Hint.

Patient communication

Having a second phone number for patients is preferable to giving out your personal number. A good option is Spruce Health.

For just a business line, try Google Voice or RingCentral.

Inventory management service

You'll need this if you do in-office dispensing. Options include MDScripts and Flexscan.

E-prescribing

Some EHRs offer this as an integrated tool. Standalone options include MDScripts and DrFirst.

E-faxing

Options include HelloFax, RingCentral, MetroFax, and Doximity.

Dictation software

Dragon is widely used and offers generic and medical-focused versions. Apple users can use Siri dictation.

Text expander/macros

Tools like TextExpander or Breevy let you specify snippets that automatically expand into full blocks of text.

Other useful services

• Dropbox - cloud storage (HIPAA-compliant with Business account)
• Rubicon - consult specialists network
• IntakeQ - customized web forms and e-signatures
• FollowUpThen - schedule email reminders

Malpractice insurance

Consider involving an independent broker familiar with direct primary care. Quotes vary hugely state-by-state. Ask for part-time rates since you won't be fully booked in early days.

Worker's compensation

If you employ people, you'll possibly be required to have a workers' compensation plan. Check state-by-state laws.

Disability insurance

If you have employees in CA, HI, NJ, NY, or RI, you are required to provide some form of short-term disability insurance.

Business interruption insurance

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

Commercial property insurance (if applicable)

Protects your physical office space and equipment.

Commercial auto insurance (if applicable)

If you use vehicles for business purposes.

Decide whether to do any in-office testing

Many commonly performed in-office labs can now be performed by patients using home testing kits (HIV, Hep C, Strep, UTI, lipid panels, TSH, HgA1c, PSA, Vitamin D). See offerings at testkitsathome.com.

To do CLIA-waived tests: file for a waiver

Fill out a CMS-116 form and submit it to your state's CLIA Agency.

Additional requirements in: AZ, CA, CT, DC, FL, LA, ME, MD, MA, MI, NV, NJ, OR, PA, WA, and Puerto Rico.

Consider offering physician-performed microscopy (PPM) services

PPM is the next level up from waived status. It lets you do all waived tests plus microscopic procedures. However, it requires compliance with multiple CLIA subparts and is probably not worth the trouble early on.

Maintain best practices

Check out the CDC's best practices document for CLIA-waived facilities. 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.

Determine if you are a covered entity under HIPAA

Check out DPC Frontier's thorough discussion of HIPAA. If you are not covered, feel free to ignore the rest of this section.

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. Once completed, publish the notice to your website.

Draft a Release of Records Authorization Form

HIPAA requires you to have this form on file for any disclosure of protected health information for purposes other than treatment, payment, and health care.

Keep an Accounting of Disclosures log for auditing purposes.

Draft a Patient Consent Form

Though not required by HIPAA, this lets the patient approve certain forms of communication (email, text, phone calls, answering machines).

Gather and maintain proof of HIPAA compliance

Full compliance involves writing a Breach Plan, Training Plan, Communications Plan, Disaster Recovery Plan, Audit and Monitoring Plan, and a detailed Policies and Procedures Manual. Check out the AMA resources to get started.

Gather Business Associate Agreements

You need a signed BAA from every company/product/service that handles your patients' health info. See a template here.

Find a biohazard/waste disposal service near you

Essential for proper disposal of medical waste.

Follow best practices when dealing with hazardous chemicals/waste

Use safe sharps, protective equipment, universal precautions, and clearly marked waste containers.

Maintain a list of hazardous chemicals in your office

Keep it available to employees. Print Safety Data Sheets for every chemical in stock (find them free online).

Buy a fire extinguisher and mount it on the wall

Basic safety requirement for any workplace.

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 easy online OSHA training.

Know how to report incidents to OSHA

Every employer must report workplace fatalities or hospitalization of three or more employees. Report online here.

With more than 10 employees: draft an emergency action plan

Required for employers with more than 10 employees. See OSHA's sample plan.

With more than 10 employees: do incident reporting and logging

Fill out OSHA Form 301 for all workplace illnesses/injuries. Use OSHA Form 300 for logging and Form 300A for annual summaries. All forms available here.

Add your practice to the DPC Frontier mapper

Go to dpcfrontier.com, click "Physician Login", create your account, and follow the instructions to create your mapper listing.

Add your practice to the Atlas.md map

Get listed on the Atlas.md DPC practice map to help patients find your practice.

Practice teaching people about DPC

Get your 30 second description of DPC down pat. Iterate on your language and pay attention to what patients find compelling. Direct interested patients to DPC Nation.

Create two Google Business profiles

Go to business.google.com. Create two profiles: one for your business, one for you as a physician.

Make a Facebook Page for your practice

Post regularly: preventative health tips, comments on current events, PSAs, and DPC developments.

Claim your profiles on online review sites

Update your information on Yelp, Vitals, RateMDs, WebMD, and Healthgrades.

Get professional photos taken

Post them to your Google profiles, Facebook page, social media accounts, review sites, and website.

Optimize your website for patient conversion

Your website is often the first impression potential patients have of your practice. Make sure it clearly explains DPC, has easy-to-find pricing, and makes it simple to sign up or contact you. Purpose-built platforms like DPC Spot are designed specifically for DPC patient acquisition.

Invest in SEO (Search Engine Optimization)

Help potential patients find you when they search for doctors in your area. SEO is a long-term strategy that compounds over time.

• Optimize your website content: Include relevant keywords like "direct primary care [your city]", "DPC doctor near me", and "membership medicine [your area]" naturally throughout your site.
• Create helpful content: Write blog posts answering common patient questions about DPC, health topics, and your services. This builds authority and attracts organic traffic.
• Build backlinks: Get other websites to link to yours. Reach out to local business directories, health blogs, and news outlets.
• Write guest posts: Contribute articles to local publications, health websites, or business blogs to build your reputation and earn backlinks.
• Claim local listings: Ensure your practice is listed on Google Business, Yelp, Healthgrades, the Atlas.md DPC directory, the DPC Frontier Mapper, and other directories with consistent name, address, and phone number (NAP).
• Get reviews: Encourage happy patients to leave Google reviews. Positive reviews improve local search rankings.

Brainstorm ways to get free exposure

Think about where lots of people go. Win over social connectors. Think about subpopulations that benefit from DPC: elderly, athletes, uninsured students, employers. Make a list of tight-knit communities where DPC could spread: country clubs, rotaries, bingo clubs.

Get a logo

Find a local graphic designer, someone on Upwork, or use 99designs. Don't try to design it yourself!

Custom printed stationery and marketing materials

Use Canva to design flyers, brochures, business cards, posters, signs, envelopes, and stationery.

Disseminate your marketing materials

Put cards/flyers at local gyms, day cares, YMCAs, universities, grocery stores, benefits consultants, and health establishments.

Ask for referrals

Chat with urgent cares and specialists nearby. Pitch them on DPC.

Check for retiring physicians nearby

They may be interested in working as an employed physician at your practice, or may send their patients your way.

Network with other small business owners

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

Reach out to nearby self-insurance TPAs/brokers

The DPC model complements high-deductible, low-premium plans. Brokers could bring an entire company of patients.

Talk to the specialists you refer to

Specialists tend to like DPC practices - they get paid in cash immediately. They may direct patients to you.

Consider paying for advertising

• Print: billboard, newspaper ads (generally poor investments)
• Local radio: good for explaining the DPC model to a targeted local audience
• Facebook: "boost" posts to reach people in your area
• Google Ads: specify exactly which search queries to show up for
• Yelp Ads: target people actively searching for doctors in your area

Make advertising partnerships

Partner with local gyms, YMCA, and health clubs. Exchange marketing materials and offer "exclusive partnership discounts."

Set up a referral program

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