Advice for Start-Ups


(Dr Rob Lamberts) #1

I was recently asked for advice in the formation of a business plan for DPC. I wrote this list for the person, but could have probably done much more. Love to hear others’ thoughts, additional points.

  • Keep things as simple as possible. The success of the practice depends on one thing: having a large number of active patients paying monthly payments. Addition
  • There is one thing that appeals to people far more than any other thing: access. People want access to their physician and to the staff. All other things are just dressing.
  • It is very simple to cover overhead - I was doing it by month 3. It’s harder to pay physician salary.
  • Online communication is essential, but use whatever tools people will use. We use phones, secure messaging, email, and in-office communication.
  • Office visits are simply a means for communication and keeping your office open for patients is key to success. Handle problems on the phone, via messaging or whatever else works, whenever possible (and reasonable)
  • Having a copay for office visits is a waste. It doesn’t earn much money at all (compared to monthly fees) and sends totally the wrong message. Don’t worry about folks abusing the “free” visits; they don’t. I have 700 patients and don’t have that problem.
  • Minimize profits on anything besides monthly fees. The low fees on labs, procedures, whatever else, are things that make your practice harder to leave. Keep the cost of leaving high.
  • Don’t charge too much on monthly fees in younger populations. All that does is select out the people you want: healthy people who don’t use you often and faithfully pay for your care. Higher fees narrow your population down to the high-utilizing population in younger patients.
  • Marketing early - talk to local news organizations, business associations, use Facebook to market locally.

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(Lissa Lubinski) #2

This is very helpful. Also, which I think you mentioned in the feed on my membership question, is the idea of offering lower price for younger healthier people. I know there are hundreds of ways to price your membership, and I have some hesitation to do age-based membership, but on the other hand, it might make sense to avoid overpricing the younger population. I was thinking 0-30 (~$30), 30-60 (~$50), and 60+ (~$70) as brackets…thoughts?

(Robin Dickinson) #3

@lklubinski I’m going to write more later because I think this is a great idea for a thread but I just wanted to mention that my most time intensive patients are “healthy” people in their 20s. My 60+ tend to be sensible, calm, and either refuse intervention or have something so serious it needs a specialist. So our visits are rare and easy. My 20-30 are more likely to be dramatic about a head cold or sprained ankle, page me because they have a zit on the chin and want it injected today because they have a big date coming up, etc. Just something to think about… (As you know, there’s a whole thread on this here.)

(Dr Rob Lamberts) #4

My patients have absolutely no problem with age-based fees. My experience is different than @Robin_Dickinson in that my younger population (20’s, 30’s) are generally wanting in-out visits and do not want me to spend too much time with them. They just want me to be available when they need me, so it’s important that we have an open enough schedule. My fee schedule is similar to that, although I do
Age 0-18: $30/month
19-30: $35/month ($10/month if they are away in college)
30-50 $45/month
50-65 $55/month
65+ $65/month

  • I’ve had no problem with this. And patients are not turned away by the cost.

(Robin Dickinson) #5

Isn’t it amazing how different every practice, every population, every physician is? That’s why I think it’s so great that we can all chime in about our own experiences. I’ve always attracted higher needs patients (think fibromyalgia, childhood trauma, mental health issues, etc) so I know that I need to account for that.

My advice to any new DPC doctor:

  • You are a wonderful physician and you could be dropped off naked in the middle of nowhere with nothing. Anything in addition to that is just there to make you comfortable or to help you do a better job of doctoring. If it doesn’t do one of those two things, you don’t need it.
  • You are smarter than you think you are. We have developed learned helplessness thanks to the modern medical system. If a housekeeper, mechanic, and electrician can all run their own businesses, so can you. I remember when I started, I worried I wouldn’t know how to fax something or send a referral or buy supplies. But if you can run a household, you can run a business. If you can figure out how to use your email and buy something on Amazon and order a pizza online, you can figure out the technology.
  • Define your niche. Who are your favorite patients? Define them as closely as you can. Mine are people who are uncomfortable or unhappy in medical offices, most likely come from working class backgrounds or are creative or the black sheep of the family, who prefer to avoid medication if there’s another way, whole families (rather than kids see peds, mom see gyn, dad sees IM), who lead interesting lives and tell me all about their lives, maybe struggle with depression/etoh/childhood trauma/etc. Where do those people congregate? What other services do they use? Who are the best people to connect with to find your population? For me, midwives, acupuncturists, urban farming organizations, and word of mouth through current patients have been my best referral sources. If you love seniors, you might want to target estate planners, travel agents, volunteer organizations in which most of the volunteers are seniors, churches, etc.
  • Low overhead means increased flexibility. Try to keep that overhead down. The best way of doing that is to question everything. Anytime I think I need to buy something, I instead ask myself if there’s something I already have that would serve the same function and if it’s something I actually need or if it fulfills some emotional fear. Anytime I think I need to hire help, I first ask myself if there’s an inefficiency I could fix instead.
  • But don’t be afraid to pay money to improve your happiness. I hate paper so I pay for Shoeboxed. I hate admin so I have an EMR that has everything completely integrated. I get stressed out being on call if people can text or call straight through to me so I have a phone system that allows for good boundaries. I don’t pay for inefficiency. I do pay for sanity.
  • Have good boundaries. If you feel uncomfortable or stressed about something, you probably need better boundaries.
  • Have a back up plan for income the first year or two so you aren’t stressing about it. Being able to turn away patients who are not a good fit should not be a luxury.
  • Be yourself. Present a version of you that appeals to your target population but that you can enjoy being day in and day out. Offer services that are needed for your target population. But if you don’t enjoy doing something, then don’t. You do not have to be the same as some other DPC. There isn’t a rule that you have to text or you have to offer EKGs or you have to do IUDs or you have to jump through flaming hoops while juggling. Patients are used to having to go all over for everything and just the fact you sit and listen, have open access, etc is just astounding to most people. If not offering a particular extra is a deal breaker for a particular patient, just let them go. You are already doing something that almost no one in your area is doing.
  • Check out the prices for DPCs in comparable geographic areas but then do what works for you. Currently a quarter of my patients are under 10. The majority are under 40. I’d be killed on age based fees so I do a flat monthly fee based on number of family members. But that’s not how it is for everyone! Also, don’t be afraid to adjust your prices. I opened before the ACA and Medicaid expansion took full effect so I had a lot of patients with very very low incomes who were desperate so I kept my prices low. After the Medicaid expansion covered the worst off of my patients and once there were other DPCs in my metro area charging twice what I did, I went ahead and increased my prices. I lost a total of one family. No big deal.
  • It will take awhile for both you and the patients to get used to this different way of doing things. I got really anxious the first few times I diagnosed a rash with just a few photographs and a conversation with the patient. I was so used to FFS, it was hard to remember that we only had to have an appointment in order to charge them money. Conversely, I see patients in the office without a problem if they just have a lot of questions or need to discuss something and are more comfortable in person. I don’t have to have a billable diagnosis to spend time with someone.

That’s all I can think of right now but I’m eager to hear other opinions!

(Robin Dickinson) #6

@DocAu @Wellpc You’re both in an interesting spot to chime in on this…a few months in to a new practice. What do you wish you’d known before you started?

(Lissa Lubinski) #7

Incredibly helpful and well-said! Thank you! This message is what I need to hear right now. What phone system do you use and what does Shoebox offer beyond your EHR? Thank you!

(Robin Dickinson) #8

@lklubinski For phones I use Answer Advantage. I know people who use Grasshopper or others. I chose AA because their customer service was great. After years of putting up with crappy customer service, that’s now my first criteria. If the customer service is poor, I don’t care how amazing or inexpensive the product it.

Shoeboxed is for business receipts for taxes. I just shove them all in an envelope and drop it in the mail and they appear in my shoeboxed account. Or forward the emailed ones there. Every quarter my husband sits down and matches up the receipts with my business account and makes sure they are all there. Previously, I would have been screwed if I’d ever been audited on my taxes…I’m just not that organized. But having someone else do all the annoying part and then just tying my husband to the computer once a quarter to do that part has worked out really well (I otherwise handle all the rest of our finances, taxes, everything so we made a deal I’d continue to do everything else in return for that one little thing).

(Jack Forbush, DO) #9

As someone who does a crapload of OMT (Osteopathic Manipulative Treatment) and prolotherapy, I have found the “copay” a key element in overutilization

(Jack Forbush, DO) #10
feel free to drop my name to Scott or Parker!

(Dr Melanie Story) #11

This is an interesting option per the website. What are some of your favorite options of this service? I find the text messaging to the landline something of interest as we have an office cell phone and I like that this option would allow for text only during business hours.

(Jack Forbush, DO) #12

My “likes”:
-phone system is “live” even in the event that the electricity and internet go down at the office
-flexible re-routing of extension and customizable “tree”
-I can have an “extension” anywhere there is an internet connection…kind of neat to go away somewhere without anyone knowing about it!
-love the follow-me feature
-customizable “group” rings per menu selection, ie if a caller presses “4”, I can have more than one extension ring or I can have it ring my extension and cell phone, etc

(Robin Dickinson) #13

Yes, these are all reasons I love mine too! (Answer Advantage) I honestly can’t imagine doing an old fashioned physical phone system. Too nice to go anywhere whenever I want and still be “in the office” as far as phones are concerned!

(Jack Forbush, DO) #14

tis nice…happy with Answer Advantage?

(Robin Dickinson) #15

Yes. It’s one of those things I don’t really notice because I never have a problem. But they have great customer service…I was having an issue with my cell carrier (not AA) and they were very responsive in helping me even though it ended up having nothing to do with them. It sounds like most of the products out there are very similar.

(Jack Forbush, DO) #16

Yeah, I think most are similar…the biggest bugaboo with VOIP is the consistency of internet connectivity both for each of us, but also for the VOIP carrier itself…Not sure who Answer Advantage uses for their connectivity backbone.

(Robin Dickinson) #17

I actually have no idea but I’ve never once had a problem with them. Just with my cell service depending on where I am so I have a cheap phone with a different carrier I keep just in case my cell doesn’t get reception. It sounds silly but I can’t stand not being able to get through!