On-Site DPC?
I Love It and You Can Too

Being an on-site doctor is a great way to practice Direct Primary Care (DPC). As the Direct Care movement grows, it’s gaining a whole host of new and creative opportunities. Through my own experience and connections within the DPC community, I’ve discovered that many different types of DPC practice have the ability to thrive.

On-site physician positions are trending toward DPC

Historically, most on-site providers were mimicking fee-for-service (FFS) medicine because that’s what everyone knew. These older care models acted like on-site urgent care with a low monthly fee; patients were paying little and receiving care worth little. Now, employers are realizing that there’s not much value in typical American healthcare. Sure, it may avoid a few urgent care visits or workers’ comp claims, but the real way to impact patients’ long-term health is with broad scope primary care, especially by focusing on chronic conditions.

Developing relationships with patients requires research, time, and physicians who are willing to learn on a regular basis. That’s what DPC is all about. It’s about building strong doctor-patient relationships, because strong patient relationships derive healthier outcomes. A good DPC doctor can get  a phone call from their patient and know immediately all the issues at play. Many on-site physicians are working toward this goal, so it makes sense that many on-site clinics have shifted from an urgent-care model to one that focuses more on primary care. While they may not always use the phrase Direct Care or DPC, the shift is both visible and meaningful.

Benefits of practicing on-site DPC

From the physician perspective, being an on-site DPC doctor offers a whole host of benefits:

• You don’t have to worry about marketing or acquiring patients.
• You get to focus on clinical  medicine with fewer business headaches.
• You practice like a DPC physician while earning the same money as a traditional physician.

Every doctor I know would rather do clinical work than administrative tasks. Since moving to the on-site space, I’ve found more of my time is spent in the clinic than in any other work arrangement I know.

The three-part definition I’ve always used for DPC is:

1. You charge a periodic fee (typically a monthly fee).
2. You don’t bill any third parties on a FFS basis.
3. If you’re charging a per-visit fee (which most DPCs do not), that fee is less than the monthly fee.

A whole host of practices fall under the definition of DPC. While the majority of my clinical practice is on-site in the prison system, most on-site DPC physicians work on-campus for large employers. Both  fall under the definition of DPC and more broadly fit into DPC’s philosophy because:

• They don’t take on a risk relevant to the insurance commissioner.
• They use a model that encourages patients to see primary care physicians frequently(unlike FFS).

When I first started practicing medicine, I understood the landscape well enough to know I wanted to do DPC. I dipped my toe into correctional medicine, thinking it would only be a small part of my practice, and then expanded when I learned correctional medicine is much closer to a classic DPC practice than I expected. In correctional medicine:

• I spend more time with patients--each visit is often 30 mins or more.
• I do deep dives into complicated patient issues.
• I don’t do coding, FFS, or deal with insurers.

Of course, the prison system also has some unusual traits. For example, my follow up is excellent--I don’t have to worry about patients going anywhere because they literally can’t. This can lead to  unusual communication dynamics too, because some of my patients will get upset with me when I give them bad news. In a traditional practice, the patient would likely go elsewhere, ending the relationship, but as their assigned doctor I have to keep offering them the best care I can.

Since working in correctional medicine, I’ve learned of other similar areas of practice where an on-site physician can practice DPC. For example, the PACE program provides all-inclusive care for the elderly. It’s a program under Medicare designed to maintain patient independence while controlling chronic conditions to keep them out of the hospital. Just like any DPC, there’s no need for any FFS billing or coding.

These different opportunities opened my eyes to the wide array of possible ways to practice DPC. I love working in DPC, and love help other physicians make the same leap to a happier life providing improved care.

6 tips for becoming an on-site DPC physician

1. Choose the right position.

Finding a position can be tough, so I recommend tapping into the DPC network. I post career opportunities on DPC frontier, and community-members can post opportunities there as well. Additionally, the Hint community can be a valuable resource for learning from other doctors and experts.

Once you find a position, I recommend vetting the position to make sure it’s the sort of DPC you want. It’s safest to visit the site several times to get a feel for it. If you’re at all unsure, consider signing on part-time to ensure it’s what you want before you take the plunge into full-time. Without vigilance at this step, it can be pretty easy to miss things and end up in a role that wasn’t quite what you expected. When inspecting a job, I’d suggest you:

• Pay attention to the job’s clinical design
• Pay attention to their advertising
• Ask them directly about DPC

If you join the wrong practice, you risk either having a disagreement with the employer or the employer wanting to change the arrangement to shift away from DPC. A little time and energy spent carefully choosing a position can save you a big headache in the future.

2. Develop the same strong patient relationships on-site as you would have off-site.

Practicing medicine is first and foremost about providing high-quality care. No matter the context, being a helpful physician requires establishing trust and rapport. This can be especially important to keep in mind when working on-site, because at a lower volume site patients may effectively be assigned to you instead of having chosen you themselves.

3. Expect a small number of administrative headaches.

If you run an independent medical practice you’re going to have a lot of administrative duties. Patients will come to you with any number of insurance situations, from Medicare or Medicaid to a high deductible plan to no plan at all. In DPC, these administrative requests are fewer, but still happen from time-to-time. Practicing on-site DPC, the administrative headaches are even less frequent because all your patients typically fall into the same limited third party bucket. I spend less time on administrative tasks than traditional FFS and independent DPC doctors. Additionally, the problems are  easier to handle because they always the require the same paperwork.

Of course, you’ll still have administrative headaches like a traditional DPC practice, such as trying to acquire a medication that you can’t find in a cheap generic format, but you can significantly streamline your approach since you’re only dealing with one entity.

4. Educate your employer so you can keep providing quality care.

Ideally, you want to work with an employer who won’t request things that will worsen your care. For example, some on-site physicians are pressured to document in a specific way (e.g. coding). The best way to avoid these types of problems is to communicate to your employer the value of DPC, including:

• The importance of a physician using their time practicing medicine instead of recording their actions.
• The value of developing a rich, trusting relationship with their patients (which takes time).
• The value of managing chronic conditions to avoid ER visits.

If you still get pushed to engage in practices that might worsen your care, you may need to decide if the requirement is obstructive enough to prevent you from practicing effectively. If it is, it may be time to look for a new position.

With good communication between you and your employer, however, this doesn’t typically happen. Through healthy communication with my employer, I’ve been fortunate never to run into this problem.  

5. Communicate your value to both patients and employers.

In the traditional DPC setting, you only have to communicate the value of your care in a way that makes  sense to the patient. As an on-site doctor, you have to communicate your value to the employer too. I’ve found the most objective and important data is the positive effects you’re having downstream:

• If hospital visits are down, ER visits are down, and patient requests are down because their chronic conditions are controlled, then you are doing well.  All of these measures translate to fewer missed days of work, higher productivity and bigger profits for the employer. Thus, the results from the care you provide has intrinsic value to your employer’s bottom line.

In the correctional space, we also track quality related to certain chronic conditions. We trend  the control of blood pressure, blood glucose readings, and track how many times a patient has had hypoglycemia. These are fairly standard and non-controversial measures requested by the state.

Because the prison has staff specifically for these tasks, I personally don’t have the burden of tracking them in an excel file. When we’re audited (which happens frequently since we’re state-regulated), they look at quality markers. These haven’t been a problem for my practice at all, but they’re still important elements to notice when picking a role. You’ll want to ask questions to make sure the role is close enough to what you want out of practicing DPC.  

6. Check out DPC Frontier and contribute.

I founded DPC Frontier as a free resource for all DPC physicians or supporters promoting the movement. In addition to the DPC mapper, where I create a physical map of DPC practices in the nation, I’m constantly adding to the career opportunities page. If physicians are looking for roles or are aware of available openings, it’s a great place to peruse or contribute. It’s also completely free because I just want to help other interested doctors find ways to practice DPC. I'm happy to be a part of the movement that’s saving family medicine.