Micropractice DPC model

(Lauren Hedde, DO) #1

I’m curious if there are other DPCs out there trying to stick with the lower overhead, low to no staff, ideal medical practice aka micropractice model? That’s what we have and would love to brainstorm and hear ideas from other micropractice-style DPCs about money saving tips to keep overhead low or lower it even further!

(Dr Brian Pierce) #2

That’s how I started two years ago. I’ve expanded to a bigger 3 exam room space after subletting but otherwise still pretty IMPish.
I have one FTE who’s very valuable (MA, phlebotomist plus office manager skill set).

Most DPCs seem pretty close to IMP/micropractice just because of the need for low overhead during startup and the simplicity of the (pure, not hybrid) DPC model.

(Robin Dickinson) #3

I’m still doing micropractice and I started in 2012. It gives me the flexibility I’m looking for. I have a teenager tech support who only helps a few hours a month and I’m “borrowing” another DPC’s assistant the next couple months for a few hours a week to help with chart reviews for my stupid MOC practice improvement but otherwise it’s just me!

I started copying out my answers to people all in one place. I sometimes end up referring people back to that. I don’t know if I tackled all the info on low overhead but I’m happy to think up more! My overhead is consistently under $2000 a month except my own take home. That allows me to work as much or as little as I like and keep my practice affordable for patients (I’m a safety net clinic): https://docsteppingout.wordpress.com/

(Lauren Hedde, DO) #4

Thanks @Robin_Dickinson . I love your website and your thoughts about portal use. When we started our practice as a DPC/Micropractice, I thought it made so much sense (and still do) but am shocked at how few physicians go this route and wonder why that is. I like the idea of trying to help new DPC docs see the ways to make a micropractice work well for them (and save so much time, money, energy!). I’m gonna read your blog more and see if we can share anymore saving ideas. Our overhead stays around 4000 absolute max per month (usually less and there are two of us) but went up to this from the 2s after we hired a marketer to help to see if that would speed up our new patients per month acquisition rate. Not sure it’s really panned out honestly but still too early to tell. I stopped taking patients and am full (for now anyway, with all my little kiddos at home) and @drturshen is taking everyone who’s new. But, we’ve always felt the only downfall of our micropractice style is slower acquisition from less money on marketing (or that’s what I’ve assumed anyway) and coming straight from residency (no panel to draw from). Would be intrigued at how you and @brianpierce have found your growth rates as micropractices?

(Robin Dickinson) #5

@DrLauren Now that’s an interesting side topic that I see you also addressed here Favorite Marketing Strategy.

I specifically chose micropractice and low overhead so I wouldn’t have to worry about the growth rate. New patients are SO much more work than established patients so I like spreading them out. But I’ve never had trouble getting more when I want them (see other discussion).

I just invited another DPC doc who closed her practice to come join us on this discussion who isn’t yet on this forum. I hope she does. She just closed her DPC and said that if she had it to do over, she would have stayed with a low overhead micropractice model.

Every time I feel like I need to hire permanent help, I instead ask myself if there’s something I’m doing that’s inefficient. And so far, there always has been. I would rather have everything run as efficiently as possible than pay someone to run things inefficiently!

(Lissa Lubinski) #6

This forum topic is extremely relevant and helpful! Thank you all. I am starting June 1 and am planning on the DPC Micropractice model for all the positive reasons you all have highlighted. I want to know that I might only need 30-50 patients or so to make my overhead (though I’m anticipating/hoping that I would be able to care for 400 or so while my 2 boys are little and 500-600 when they’re older. But we’ll see. I am glad to see that this model is working for some of you. I also am intimidated at the idea of hiring a staff member and having to worry about training, hiring, firing, the relationship and potential impact on patients/practice. I know that the right staff person can be ideal in many settings, and a suboptimal fit can be a stressful situation I’m not interested in dealing with. At least not yet.

(Robin Dickinson) #7

That’s exactly why I started as a micropractice and have stayed one. The risk is small. My kids are small too, but growing. It’s been nice to have my panel grow gradually as my kids have grown. I use a simple calculator (like this https://youtu.be/bEnqdN_FzUc) to figure out my finances and overhead has a huge impact. I also find that my flexibility is greater without any staff. I’m not trying to keep someone busy during the slow summer months. Instead, I work very little.

I know @Brieseefeldt has a wonderful assistant but is otherwise on her own and that can work for some people too.

I wonder too how much personality has to do with it. I’m a true introvert and my time with my patients is adequate work socialization for me. Some people need more than that.

(Lauren Hedde, DO) #8

@lklubinski Happy to help with micropractice-specific questions here! It’s been the best decision we made in my opinion. We have such amazing flexibility! And, there are some great tax-related and investment-related savings once you’re ready for all that.

Tax and Investment Savings in Micropractice
(Robin Dickinson) #9

@DrLauren @lklubinski @brianpierce @Brieseefeldt
I’ve started a new thread here to discuss the tax and investment savings in micropractice.

Otherwise, just carry on with this conversation!

(Mary Medeiros) #10

Hello all, thank you for creating this thread, this is a great and important conversation for anyone looking to start DPC from scratch. I am hoping to get my office space ‘back’ from the contractor today, and preparing to fully launch in about 2 weeks with just myself and a part-time administrative assistant. I currently have 19 patients that I have been managing through home visits (and non-visit care i.e., text/email/phone) and I agree just on-boarding this small group has already been busy, but has provided me an invaluable learning curve for identifying and filling gaps in the practice model so far.

Two questions for the time being:

  1. Do any of you draw blood on your own for lab samples? Or perhaps know of any DPC micropractices where the provider does this (my only employee so far is admin only and I am hoping to be able to operate without a 2nd employee for a while but not sure how this will pan out in terms of time efficiency)?

  2. How do you manage documentation? Coming from very strict documentation environments (academic, then corporate group practice), I don’t quite know where to draw the line between what is truly necessary for continuity of care (we do all need memory jogs even for patients we know well) vs what is “required” (vis-a-vis HEDIS/MIPS/MACRA type junk). I do also have a set of Medicare/Medicaid patients for whom I feel like I need to keep paper trails “just in case” of some type of audit, and I’m most curious whether anyone approaches these patients any differently?

Thank you!!

(Robin Dickinson) #11

Yes I do. If you can do other procedures, you can draw blood. There are great videos on YouTube to show you how. That said, I can send my patients to the lab for the same price to them so much of the time I send them or get labs before their appointment so we can review at the appointment. If you think the total number of times you’re going to draw blood for the whole year, it’s still nowhere near hiring an MA just for that.

I’m a hybrid DPC 75% Medicaid 25%. I like really complete documentation when appropriate and not when not it’s not. In my EMR, I have “chart parts” for all the standard stuff for billing and for my own use and then mix and match as appropriate. So a note about depression looks about the same for both (I bill based on time for Medicaid), as does a visit for something like htn or diabetes where all that ros and such is actually useful for me too. The difference is something like freezing a wart. For my DPC patients, I have a single sentence note I pop in, basically “has wart, froze x3, patient tolerated well, the end”. For Medicaid, I still have a full note with all the parts so I bill as office visit for diagnosing plus procedure. You’ll refine what you do to how you work. I have REALLY detailed/long patient summaries that I post on the portal. Some people don’t.

The other huge difference is I just don’t generate as many office visits in DPC. A rash is just a phone call or portal message and a photo uploaded in the portal. That cuts way back on documentation… I’ve chart parts for all the stuff I can take care of without an appointment so it only takes a moment to look at the photo and pop in the instructions. Same for hemorrhoids, pink eye, etc etc etc

(Mary Medeiros) #12

This is awesome Robin, thanks for all this input!

Can I ask what EMR you use that you can upload photos into the patient portal? That’s very cool.

Thanks again!

(Robin Dickinson) #13

@Mamedeirosmd I use MD-HQ. I think most people on this forum use either Elation or MD-HQ. It’s all good your brain works and what meets your needs. Here’s how the portal works: https://youtu.be/Re-FXXft1_g

Some practices just get things like photos via email. I like keeping it all through the portal.

Keep asking questions! No need to reinvent the wheel. :smile:

(Trinette Moss) #14

I have a micropractice. I do have someone doing front office work but I can get by without her if I absolutely wanted/needed to.

I draw blood and so does my front office person since she is a retired nurse.

Documentation for Direct Primary Care is easy. You can just put in the salient things. That said, I am used to “buffing the charts” for coding and it’s a habit to include some things, but I’m learning I can cut down on things I write and template most of the rest. [Breevy is great for templating via macros]

I use ElationEMR

(Robin Dickinson) #15

Me too! It’s like learning how to throw a ball a different way when you’ve done it the same way forever.

(Kirsten Harrison, DC) #16

Hi everyone, I’m new to hint, DPC, doctoring (graduated 12/16), and business. I’m not new to life, as I’m in my mid 40’s! :slight_smile: I’m intending to start a micropractice DPC so this thread seemed an appropriate place to start in this community. Thank you all for your input. I’ll run off now and follow couple of links so I don’t ask something that has already been covered.

(Robin Dickinson) #17

Welcome! Feel free to ask any questions that may come up for you!

(Siobhan Benham) #18

Me too, think this is a great thread. I just opened my micropractice 9/1/17. I have 7 patients.This is a great topic as I moon light in urgent care on the weekends for income but was questioning my charting in my own practice. I am using Elation.

I feel silly asking this question but want to get an answer from someone who is practicing…

If I am not credentialed with an insurance they will NOT pay for any of my orders, like labs or imaging right?

However if I’m moonlighting and work in an office Where I am credentialed patients say they can find me in their insurance pcp network, I have told them that is a different office. My NPI is for the other job. I hope to be able to opt out soon but can’t until I have a more robust patient panel.

So my question is, if someone is seeing me in my DPC practice and goes to get an X-ray, and gives me as a pcp with an NPI from a different job is this a fraud or something else not legal? It hasn’t happened yet.

(Robin Dickinson) #19

Actually, most insurance doesn’t require you to be credentialed with them for labs and imaging. In some HMOs you do need to be. But in some HMOs, most PPOs you don’t need to be.

That said, I’m not sure about the legality of seeing someone in your DPC practice vs your moonlighting. @appalenia is that an easy answer or is that something she needs to talk with a lawyer about?

(Dr Mark Turshen) #20

We have a micropractice… just two docs. We draw blood ourselves much of the time. We use practice fusion since it’s free and does enough of what we need. Open since 2014, still have no interest in staff at this point.