Direct primary care without an actual physical office


(cjs56) #1
  1. How can a physician create a direct primary care practice without an actual physical office space?
  2. It would seem to me that this would be the same as a home visit practice (going to patient homes).
  3. Also, it would seem that the physician would need to stay active with MEDICARE as most of the visits would be MEDICARE patients (home bound patients).

Home visits
(Jason Larsen) #2

@cjs56 - I have heard of DPC physicians working out of a mobile unit (mobile trailer). That’s attractive for less costs and offering pretty high accessibility for various people groups (employers / school districts / etc.).

You could definitely look at it as a home-based practice. There are some cautions to take with that, but definitely viable.

I would advise against staying with Medicare, as there are lots of Medicare patients that are willing to pay a monthly fee in exchange for care (especially home care). If you choose to stay in medicare, you need to stay far away from the membership with your medicare patients. My guess is that your compensation could be greater with membership (doing only home visits, I would recommend something in the high range of DPC, approaching more concierge services, depending on your location) compared to being reimbursed by Medicare. Plus you’d be freed from the necessary paperwork / charting, etc. that Medicare requires.

Hope that helps!


(cjs56) #3

thanks.

good network.

the school base deal with vans I am aware of because of the

severe poverty and welfare in urban…and rural…california…the only way

kids can get vaccines…via…FQHCs.

no one else could imagine it.

I am aware not to bill medicare and collect for dpc because of …“holding out as an insurance company.”

Jason Larsen is a physician?


(Jason Larsen) #4

@cjs56 - I’m not a physician, but founder of a DPC practice alongside a physician and a mental health counselor.


(Robin Dickinson) #5

@cjs56 I know a doctor who runs a very successful peds home visit practice. Parents often feel homebound because it’s such a nuisance to get kids out of the house. :slight_smile:

And actually, the majority of the home visits I’ve done (which isn’t standard in my practice but I’ll sometimes do as a favor or if it’s convenient for me) have been for kids. I even did a “mini van visit” once when a kid needed a strep test to be allowed to return to school and I needed to get my child to dance class. I just brought my kit along with me and the mom pulled up outside dance and I ran out and did a strep test on the kid sitting in her carseat!

I personally find the $650 a month I spend in rent to be well worth not having to drive all over town. But I believe that anyone avoiding a physical space could do home visits with any population. It is a whole different level of connection and understanding for a patient.


(cjs56) #6

got it. thanks dr. dickinson.

I was going to try and ask:

  1. what is the name of the free electronic medical record that I heard about on one of the web sites?
  2. Not Atlas…but another EMR.
  3. I wonder if there is source to find out the average rate of professional liability insurance for DPC practices since DPC practices I have heard tend to be lower since only 10 or so patients per day?
  4. I have heard that California can offer rates as low as $2,000 per year. But, Long Island, New York remains high at $12,000 per year (because there is only one insurance carrier on Long Island).

(Robin Dickinson) #7

@cjs56 I’m going to spread these questions out to separate topics so that you can keep the answers straight. The question about EMRs is here.


(cjs56) #8

I asked the three questions on the new topic section.

But, I am not sure if i have to send it/

i did not see a send button so I think

it automatically does through since I did not have to send the one from yesterday.

Thanks Dr. Dickinson.


(Matthew Haden) #9

@cjs56
I started out 100% mobile, and another Dr. in my group still does it that way. We can start a neighborhood house call DPC for less than $500 in basic equipment. It is definitely doable, and very fulfilling. See our DC metro area prices at www.ModernMobileMedicine.com

I now have shared office space in a wellness center on Mon, Weds, Friday. I use it mostly for visibility and connection to the local neighborhood and business association. That has been worth the rent. I often meet new patients there for intake physicals on neutral ground so we are both comfortable before doing a house call.

Subletting from an ENT, ortho or Optho who has OR days would be a viable option to keep your overhead low.

I am opted out of Medicare, and highly encourage it for house calls also. Too much red tape to stay in, and too little reimbursement per house call, unless you see a cluster of patients at a nursing home or retirement center back to back. Research your area. If there’s a shortage of house call doctors like most cities, the Medicare patients or their families will still find and hire your service. It’s us or high priced concierge doctors.

If you anticipate a slow building up of your panel, wait to opt out until you are profitable so that you are employable for moonlighting at urgent care, ER or telemedicine.

We at Modern Mobile Medicine cater specifically to families with our service, so @Robin_Dickinson is correct–there is just as much benefit to young as old and immobile. Convenience is desirable for all ages. We have mostly large families, although the Medicare and Medicaid covered individual patients were among the first to sign up because of the value.

That’s my 2-cents!


(Robin Dickinson) #10

And that is why DPC is so awesome. :smile:

Thanks for sharing your information! It sounds like a great method of getting started.

And I totally agree with this…some people opt out too soon and regret it.


(cjs56) #11

Best advice that I have had in 10 years.

Thank you Dr. Haden.

I will also review the web site.


(cjs56) #12

I am learning everyday. I could do it.

Dr. Hayden’s advise excellent…

  1. go mobile until you find suitable office space,
  2. keep Medicare until do not have to moonlight.

Although, a group practice may bill under the group’s Medicare number and it may be possible that a DPC physician would not need to keep active medicare number. But, probably still need to keep it active.


(cjs56) #13

Thanks Matt.

Regarding the neighborhood house call DPC, roughly speaking, I wonder:

  1. what the specific needed equipment would be (I assume ECG machine, blood draw equipment, urine cups, strep screen, ear lavage). Anything else that you used for start up equipment?
  2. what is a rough cost of each item for the rough total of $500.00
  3. your web site is good…very thorough and clear.
  4. Thank you.
  5. Stephen Croughan, M.D.

(cjs56) #14

Hi Dr. Dickinson.
I thought hat Liberty Share was a discounted laboratory.
But, the following are both so-called ministry cooperative programs that offer potential hospitalization coverage for patients:

  1. Liberty Health Share www.libertyhealthshare.org
  2. Samaritan Ministries www.samaritanministries.org

(Robin Dickinson) #15

@cjs56 I’m going to move this discussion about cost sharing to another thread over here


(Robin Dickinson) #16

What you need depends on whom you see and what your other resources are. I personally do not have an EKG machine. I need about 2 EKGs a year in my fairly young population (families with young children mostly). And I have a cardiology practice the next parking lot over who will do an EKG for a good price. I just have patients pay for the EKG but even if I paid for it, I’d save money over buying a machine myself!

Everything you need for blood draws is provided free by the lab generally including urine cups.

Strep tests and so forth you can buy online inexpensively. Docsavings.com usually has good prices on strep tests and cryo and urine dips. For ear lavage, I got an elephant ear wash on Amazon. A lot of equipment is available inexpensively on Amazon. I’ll also do a google search for “cheap [item I need]”. Home healthcare websites are good for things like chux. A lot of small portable equipment for peds is available from websites for midwives. Ultimately, I got most of my equipment used from the garage of a doctor who closed his private practice…the practice he joined didn’t want much of his equipment (probably because he got it from another doctor so most of it is older than me but still works just fine!)

So be creative, think outside the box, and only get what you actually need!


(cjs56) #17

Great. I was asking about the equipment for a “mobile medical practice”…home visits to elderly, etc.).

But, I think most of the equipment Dr. Dickinson was speaking of would relate to both an “office” DPC practice as well as a mobile practice.

I was just wondering if there is anything unique in terms of equipment usage that physician would need with respect to a “mobile practice”…in other words going to patients’ houses?

The other thing that crossed my mind is the suppose a physician was gung-ho on doing home visits but no one in the community wanted a physician to come to their home (all patients wanted to keep their privacy)?

I am sure this has happened and I am also sure that some patients really need a physician to come to their home.

I hove Community Hint. I think the physicians are very smart, saavy and very open-minded.

I also think that this is a very unique and powerful way to communicate.

I am going to tell you some things… on the general Community web site… about FQHC work, San Diego and California in general as well as what I think a patient would want in a home visit (I had an ill parent with Parkinson’s disease that I took care of for 10 years …with minimal help…while doing Family Medicine).

I am 6’3’’ and was down to 163 lbs. at that time.

I am back to my surfing and basketball weight of 180 lbs. now.

The other thing is that Dr. Samuels in Idaho recommended to me to use …“You Tube videos” for DPC info./knowledge.

I started yesterday and spent three hours.

I will do 2 more hours today.

“You Tube videos” are great to mostly encourage you to do something different.

Have some coffee ready…so you don’t doze off.

I finished Dr. Farrago’s book last night…I had to put it on hold to study for Re-Cert this past April.

The last twenty pages are the best…where other DPC doctors talk about their difficulties.


(Chad Weston) #18

Planning on same premise in NC. Two docs established patient panels of 3K each transitioning out of employed position to DPC. Most communication is via secure texting with anticipated <15% of contact with patients in person and likely at home. This thinking makes is tough to justify the overhead upfront. But, after off the runway that may be an expense to reconsider. Ultra low overhead at startup and use future overhead to build value to the existing practice population.


(cjs56) #19

Thanks Dr. Weston.
I was going to ask the DPC doctor in Apex, N.C. what the professional liability costs are for family medicine in North Carolina for a DPC practice…as well as…the costs for a mobile practice like yours???
How much per year? Like California, probably depends on the specific County.
I have a call put into a liability company here in California to see the rates out here.
Some DPC physicians here have told me that they pay $2,000.00 per year out here for liability.
Pretty good.
I put the call into the insurance company out here to see if they come up with the same rate.
i am going to find out the same information for North Carolina, South Carolina and Long Island, N.Y.
The latter (L.I.) is a disaster …as it always is…due to high rates and too few companies. (I think either Physicians Reciprocal or MMLIC …one of the two…went out of business).
CA Insurance company told me that DPC rates may be the same as a "concierge practice."
I will let you know how much it is out here.
As a matter of fact, I may take a day or two out of my schedule to go around with a “mobile company” here in San Diego to try and learn more of the ropes…as an observer. See what it really is like going into the home.
I have done little of this…but a few years ago.
That is, if they let me.
I would think that for “mobile practice”, a physician may have to go to an area where there are many retired patients.
I am not sure how many patient you would need for a mobile practice?
If you were lucky enough to ever get an "age mix of patients…like the “old school family doc”, then I guess you would need only 100 seniors or less since your other patients would be younger.


(cjs56) #20

As I mentioned, my mother had Parkinson’s Disease for 10 years. I was working 32 hours a week.
I had no outside help except for outside agency help which cost $12.00-$15.00 per hour.
Some churches can provide help as well.
Elderly neighbors are ones that a home bound patient needs to befriend quickly.
I was lucky because my mother could not transfer too well at the end.
So, less worry about "wandering."
I believe that a home visit physician can be the most help by simply asking the patient "is there anything specific that I can do to help you in the next hour and is there anyone you would like me to call that may be able to assist you later
on today or that may be worried about you."
If a D.P.C. homebound patient is going to pay a monthly fee, then a family physician’s most valuable asset is ADVICE from previous geriatric patient experiences.
What to avoid and what to focus on.
What caused the downfall of a previous geriatric patient? What caused another geriatric patient to become a little stronger? How can you be this patient’s advocate? The community at large may not be the patient’s best advocate.