Robert Lamberts, MD

Four years ago, I left my fee-for-service, insurance-based practice and started a cash-only, direct primary care practice (charging my patients a $30 to $65 monthly membership fee). My financial survival depends on my ability to attract and keep patients, which means that marketing has suddenly gotten much more important for my practice. Like most businesses, my best advertisement is word-of-mouth recommendations from happy patients. Beyond that, I've found that my most effective marketing tool, by far, is Facebook.

Before moving on, I need to make it clear that 

I am talking about a Facebook page for your practice, not a personal Facebook account

. It is unwise, in my opinion, to interact with patients using their personal Facebook accounts, as it gives an intimate level of access to information about you, your family, and your friends. This is difficult for our practice, as patients often are very fond of me and my office staff, and so, consider us friends. But that friendship has to have boundaries, and just as I would not invite my patients home for dinner, I keep the same boundaries in the world of social media.

The good news is that Facebook pages allow social interactions with boundaries intact. The pages are easy to set up (as long as you have a personal account), allowing you to give easy access to general information about your medical practice (office hours, location), post pictures of your office (and staff, if they give permission), and make general announcements, such as closings for holidays, etc. People can "like" your page, meaning that whatever you post on your page goes on their timelines as well. 

 has nearly 2,000 "likes," which lets me reach out easily to a large number of people - most of whom are local.

Having a static Facebook page with basic information about your practice (basically an online billboard) is only the first level of social media marketing. One of the keys to successful marketing on Facebook is to make your page interesting. Post material on it frequently, sharing information about your practice, but also sharing articles and pictures that you think people will find interesting. This takes time and a little bit of forethought about what information is worth sharing. This makes your page a place of discussion, interaction, and somewhere people can go to find interesting stuff.

If you really want to reach out to potential patients, Facebook allows you to "promote" posts that you put on your page, meaning you can make them visible to more than just those people who have "liked" your page. This does require a small amount of money, but for $20 I can make a post visible to thousands of people (usually to the friends of people who "like" my practice's page). I usually get a surge in "likes" after promoting content that is especially interesting.

For a little more money (in the $100 to $200 range), you can run an ad campaign, targeting specific patient demographics (like age, sex, or zip code) to have your ad appear on the side of these users' Facebook feeds. During a slower period in my practice, I ran a promotion where I waived my registration fee, announcing "Dr. Rob is on Sale!" The response was very good, and I easily made back my small investment.

My patients love my Facebook page. I post articles, make jokes, talk about squirrels in our attic at the office, advocate for flu shots, and generally act like a likable human being in a public setting. They will often share the posts with their friends, as if to brag "My doctor's cooler than yours." These are two of the most powerful parts of marketing: improving word-of-mouth communication, and raising the intangible "cost" of leaving my practice. I use my page to give my patients fodder to brag about our office by posting content worth sharing. This is a very powerful driver of word-of-mouth marketing. I also like to make people feel like they are part of something special, which they would lose if they ever left my practice. Having a "personal" connection with me via my practice's Facebook page does that very effectively.

I'm at the point in my business where I don't have to do much advertising to get more patients. I really feel that the time I've invested (and the small amount of money) in my Facebook page has been, by far, the most effective tool I've used to get me to this enviable point.

So what tips would I give to successfully use Facebook for marketing?

 If you are funny, use humor. Share candid photos of yourself and your staff. Do whatever you can to show that you are the kind of person people would want as their doctor.

2. Don't talk about specific medical information.

 be a place to answer people's medical questions. I've had a few people try, but they always understand when I tell them I can't help them in that setting.

3. Make your page something worth following.

 Many physicians' pages I read are as interesting as a phone book. Other physicians use Facebook as a soap box on which to lecture the general public. People don't want that. They want interesting information, and many out there are desperate for a doctor who they can be proud of.

You can see how I do it on my practice's Facebook page: 

Articles

This primary-care physician has successfully used social media to spread the good word about his cash-only practice.

Marketing a Medical Practice Using Facebook

It has been three and a half years since I made the jump from a "normal" insurance-based practice to a direct primary care (DPC) practice. To clarify, we take no payment from third-party payers (insurance or government), instead charging a flat monthly fee for all care, ranging between $35 and $65 per month (depending on age). We charge no copays, do most common procedures for no additional charge, and offer "client bill" labs (the patient pays us and we pay the lab a negotiated price) with minimal mark-up (CBC is $4.50, TSH is $8).

While this may seem an impossible business model, at 725 patients, we are profitable enough to pay me a "reasonable" salary (one that pays my bills and lets me save some) that is rapidly increasing. My collections this past month were more than $8,000 higher than a year ago, with minimal increase to office overhead. Furthermore, my quality of life and level of the care I can give is far better than it ever was in my old practice (I average around 10 patient office visits per day). I am happier, my patient satisfaction is very high (with very few patients leaving the practice), and my staff tells me they'd quit before they'd go back to the old type of practice.

If this all sounds like a fantasy, the part that I am omitting is how difficult it was to get to this point. The object of this article is not to explain the details of my practice (

), but to give some advice for those considering making the change from the hamster wheel of insurance-run primary care to the relative freedom of direct primary care. Not all who try DPC succeed. So what are the most important things to do to create a sustainable practice?

Over the last few years in my previous practice, I was increasingly despondent about the quality of care I was giving. I was desperately trying to give excellent care in a system that was alienating me from my patients. I saw DPC as the antidote for that struggle. Instead of being rewarded for sickness, procedures, and brief office visits, I was rewarded for education, spending time with people, and keeping people healthy (all of which allow me to grow my panel).

My vision gave me the ability to get through the times when money was tight. Having a much better relationship with my patients was enough of a salve to put up with small balances in my bank accounts. Additionally, my vision was contagious, causing many of my patients to evangelize their family and friends on my behalf. Happy customers are good advertisement, but true believers are even more so.â¨

I employ two medical assistants, both of whom worked for me in my old practice. This is very lucky for me, as I knew I was getting people who would not only work hard, but ones who would buy into the vision I had for patient-centered care. This is really important because, as opposed to the insurance-based practice where the doctor is the only real revenue generator, my office staff has a huge impact on patient satisfaction and retention (which directly impacts revenue). They don't just work for me; they themselves are passionate about the care we give and so feel a unique sort of ownership. They are empowered and they have an emotional stake in our success, and that makes things much easier.

The good news is that the quality of life for office staff is far better than anything they've ever experienced, so getting them to buy in is not that hard. But acknowledging that they are not just "support staff," but true care providers gives you workers who will go the extra lengths necessary to keep patients satisfied. In a start-up of a new business, you don't have time to babysit your staff. Give them vision and purpose, and you not only have less to worry about, but you have a huge ally as you build your practice.â¨

The most common error I see in failed DPC practices is that they charge too much. While it may seem like a necessity to increase cash flow more quickly, setting prices too high leads to several problems that can stifle growth and doom a practice. High prices are going to select against the patients you most want to attract. In a subscription model, the ideal customer is one who has low demand and high satisfaction with the product you offer. For example: Setting prices too high for a younger population (under 30), who are largely healthy, will discourage those who are healthy to pay your monthly fee. Far more healthy 20-somethings will pay $30 per month than $50 a month, and the ones who are willing to pay that much will often be the ones with the most medical problems. It's better to have 30 healthy people at $30 per month than 10 demanding people at $50 per month, both in the revenue and the work those patients will require. As people get older and have more problems, this rate can go up, as it is easier for people to believe they may get sick and need your service.

On the other hand, we recently raised our fees by $5 per month, as I didn't feel I was growing my salary enough to cover my personal expenses. This change netted more than a $3,000 increase in my salary, but still didn't affect my patient growth, or cause anyone to leave my practice. So it is possible to price things too low, but it is far easier to recover from that mistake than that of over-charging.

The struggle to build a successful DPC practice is absolutely worth it. Those who start now are definitely in a better position than I was, as there are far more people to learn from and many more products that make adoption of DPC easier. Still, there has to be a certain level of belief in what you are doing, as well as a willingness to go through some lean times to find that gold at the end of the rainbow. I can't say I'm there quite yet, but I'm getting real close. Yes, it works. Yes, it is much, much better.

who is board certified in internal medicine and pediatrics, practices in Augusta, Ga. In October, 2012, he left his "traditional" primary-care practice and opened a cash-only "direct care" practice.  Lamberts can be reached at 

Making the jump to direct primary care isn't going to generate changes overnight, but this doctor says it was worth it.

Creating a Sustainable Direct Primary Care Practice

I have been operating my direct-pay practice (I accept no insurance; patients pay me a low monthly fee for care) now for over two years. Two years means several things. First, it means that I am out of the "start-up phase" of the business; it is no longer an experiment, or a concept I am trying to prove. I am successfully making a living using an entirely different business model than most doctors in this country.

Two years also means that people see me differently. I have experienced a recent surge in patients joining my practice; many of whom were initially nervous about joining, but now see that my practice is stable.

The last thing that two years means is that I've had a chance to figure out what really works in this type of practice and what is window dressing. Here are the tools I have found most useful in building a successful direct-pay practice.

I am not in a typical medical office area, but instead intentionally found a homey-looking space in a commercial office complex. I designed it to feel different from most doctors' offices: comfortable and welcoming. From the outside it looks like a house, not a medical office, and I've filled it with comfortable furniture, pleasing decorations, and coffee for patients on request. Patients will make a point to come in just to chat; and we can because our schedule allows us the extra time to connect with our patients.

This was my biggest start-up expense, but I believe it was absolutely essential in building a new mindset in my patients.

I now have two nurses (to handle 600 patients), both of whom came from my previous practice. Both of my nurses are zealous in their belief in the direct-care model. Part of their zeal comes from the fact that their lives are so much better in this new office setting, but also, much of it is because they truly like to help patients. My practice model is all about customer service and exceeding expectations. I am really fortunate to have staff to whom that focus comes naturally.

Essential #3: The right communication tools

The one thing my patients value the most in my practice is access to me and my staff. If they have questions, they can call the office or reach me via secure messaging. While it's technically OK to use e-mail for communications (as long as patients sign a HIPAA waiver), I found that most of my patients value security in communication over ease of use. Here are three ways I communicate with my patients:

 I use Ring Central which is a VOIP Internet phone system, which allows me to cheaply have a complex phone system. Voicemails are e-mailed to me; faxes are also received and turned into e-mails. I can text with patients as well as hold a conference call. It has its flaws, but overall we get a lot for a low price.

 I use Twistle, which is a HIPAA-compliant "chat" system. This might be the tool my patients value the most. It works like a secure chat, with apps available for Apple and Android phones. It also notifies me via e-mail when patients have tried to contact me, and my nurses can be copied on the messages as well. I can securely send lab reports (as PDF files) or handouts regarding conditions as attachments, and patients can send images (rashes, wounds, etc.) to me from their mobile app.

 While I don't encourage e-mail communication, some patients prefer it. We use our own domain hosted on Google's Gmail website. It's very easy to use and extremely affordable.

I experimented with several billing systems. I initially used Intuit Quickbooks and their integrated billing features. For a while I used ADP's automatic billing system, which worked fairly well, but didn't integrate well. Most recently, a new start-up, Hint Health has built a very elegant and easy-to-use billing system specifically designed for direct-care practices. They are very easy to work with, and solve issues quickly and easily. They also integrate with several EHR systems, and are always open to further integrations.

. Not only does it provide an easy communication tool for patients and those interested in my practice, but I can promote posts to the exact demographic I am interested in. I promote any specials I am running for new patients, but I also promote posts or articles that highlight how my practice is different. The money I've invested here has paid itself over manyfold.

There are other tools I use regularly, but these are what I consider essential, and without which I could not have created a successful direct-pay practice.

is board-certified in internal medicine and pediatrics, practices in Augusta, Ga. In October 2012, he left his "traditional" primary-care practice and opened a cash-only "direct-care" practice.  His writings on this and other topics can be read on his popular blog, "Musings of a Distractible Mind" 

Patients come to a direct-pay practice for improved access to physicians. In order to deliver on that promise, a physician must have the right tools. 

Essential Tools for Building a Direct-Pay Practice

When I left my "normal" practice over two years ago and opened up my new "direct-pay primary-care" practice a few months later, I had no idea what a significant statement, "I'm still standing," would be. It's not that the practice of medicine has gotten significantly harder (much to the contrary), but running a business from start-up to steady success is something I had absolutely no training for. Despite this fact, my practice has grown close to 600 patients, and what was once a radical change in care has become a happy "normal" for me, my staff, and my patients.

Here are three things the past two years have taught me:

Here is the model I adopted (and have yet to change):

• Patients pay a monthly fee of $30 to $60 per month (depending on age). There are family discounts and a $50 registration fee. I don't require a commitment for a certain number of months.

• There are no copays for office visits. (I found copays added complexity without increasing income significantly.)

• Labs and procedures (such as immunizations) are done at cost.

• Patients get access to me via secure messaging or phone messages.

My patients are extremely happy (with very few of them leaving my care). While the increased patient panel has made caring for immediate problems a bit of a challenge at times, we continue to focus on giving an extraordinary customer experience and high value for all patients. We also continue to work to improve care for our patients 

 in the office. (Something I never did in my old practice). Finally, we still have significant room for growth, and I am finally seeing a steady-enough income to not be nervous about paying my bills at home.

Given the unusually good experience I give my patients (and the usually bad customer service given in most other practices), it would seem that people would flock to my practice. But even for people who were my patients previously, most still don't understand how paying a monthly fee could bring significant value to their healthcare. People don't understand that consulting myself or my nurses about a perceived urgent problem can often prevent a visit to the ER (or hospital). Nor do they understand the principal of turning away from high-volume care, so that we can give our patients high-quality, high-value care. Yet an increasing number of people who tried my practice but were initially scared off by the cost, have now rejoined and are gladly paying our monthly fee.

An axiom of business states that: Those working in a business must have a significant financial stake in the business's success for it to succeed. Yet there is another force that isn't often addressed: the mission of the business. My nurses share my passion for our patients, and have expressed gratitude and excitement at, once again, being able to do whatever our patients need. Interestingly, the patients themselves share in this emotion, constantly thanking and encouraging us for our work, (and being far more patient when we miss our mark). For those who think the "calling" of healthcare is lost, I emphatically offer my practice as proof to the contrary.

I think the direct primary-care model is still young, and so is still only for those brave enough (or crazy enough) to make the change. But from where I now stand, two years after making my first patient encounter (as a house call), I am confident that I've found the right way to give care to my patients. It's right for doctor, nurse, and patient - and it is right because it has a mission that works to reduce the cost of excessive and unnecessary care. My practice is not close to being perfect, and it certainly isn't easy, but it continues getting better each month - which is something I could never say in my old practice.

who is board-certified in internal medicine and pediatrics, practices in Augusta, Ga. In October, 2012, he left his "traditional" primary-care practice and opened a cash-only "direct care" practice.  His writings on this and other topics can be read on his popular blog, "

After converting to a direct-pay practice two years ago, this physician has learned a thing or two and is glad he made the change.

My Direct-Pay Primary-Care Practice: 2 Years Out

) I have written about aspects to consider when opening a direct primary-care practice. Today I am going to discuss something fairly personal: I'm going to tell you about the bad side of running a direct-pay practice. While I am glad I have made this transition, I don't want to give anyone the impression that this has been all joy and fun. Here's my story:

According to the plan I made prior to opening my direct primary-care practice, I should now be on financially solid ground. I have weathered nearly 15 months without income from my previous practice and have seen steady growth in both patient numbers and practice revenue. I am paying my bills and have recently hired a second nurse. My total patient numbers are now over 450. That's the good news.

The bad news is that my estimate was completely wrong. I had very little personal income over the past 12 months, and to survive, I've had to spend most of my savings - including retirement savings. This is the reality of starting a new business; especially one that uses a new and different business model. This is the reality my accountant warned me about before I started. This is the reality anyone wanting to make such a transition must consider.

I do not have a problem with patient demand (in fact, my waiting list is over a month long). The slow financial growth has, in fact, been of my own making. I made four choices that have kept my financial situation tenuous:

1. I chose to limit the number of new patients

. I don't want the quality of my service for my established patients to suffer as I focus too heavily on new patients.

 My practice vision is based on a having relationship with my patients, and this type of visit would be the antithesis to that vision.

. There is a fine line between underpricing and overpricing services. As it stands, there are still patients who opt out of my services because they say they can't afford them. I disagree with their math, but the frequency of this makes me feel that going up on my rates would hurt revenue more than it would help.

 I believed this was the only way I could care for Medicare patients in my model of care, yet it made it nearly impossible for me to moonlight and supplement my income.

These are not easy choices, but they seem to be the best course for me to take. Fortunately, with my forecasted growth over the next few months, I should be making a reasonable salary before my resources run out. I also should get fabulous financial aid for my daughter in college, since I didn't make much of anything last year. Yippee.

So what advice do I have for those considering the jump away from the E&M/CPT/ICD-code dance to the world where patient care is actually at the center?

 My accountant warned me about my year of austerity, but my optimism made it hard for me to believe him.

2. Line up moonlighting jobs before you make the switch, and consider all options of payment.

 My transition happened abruptly, and so I didn't have the time to consider all contingencies.

3. Keep the vision of what you want in front of you.

 I have been able to endure much fear and disappointment with the strength of my conviction that I was doing the right thing. Often the passion of these convictions was the energy I used to push through the hard times.

 Things are in great flux right now and many of us "pioneers" are working to make the path for future physicians easier. I believe this practice model will change everything, and hope that eventually there will be a huge influx of physicians making the switch. This will only happen if better models are in place.

I hope this is both encouraging and discouraging. It is truly far more enjoyable to practice in a setting without the burden third-party payers bring. I love my job more than ever. However I can't enthusiastically recommend that every doc who reads this should follow my path - yet. That may change in the near future.

is board-certified in internal medicine and pediatrics, practices in Augusta, Ga. In October, 2012, he left his "traditional" primary care practice and opened a cash-only "direct care" practice.  His writings on this and other topics can be read on his popular blog, "Musings of a Distractible Mind" 

Fifteen months into a direct-pay practice, this physician recommends building a financial reserve first for any physician considering a similar path.

Funding a Direct-pay Medical Practice 

While the decision to change to a direct-pay practice can be the most difficult one a physician can make, there is a second decision that is nearly as difficult: How to charge for services. This decision not only affects the bottom line of the practice, but can greatly affect the type of care that is given.

Looking for more ways to boost reimbursement at your practice? Join experts Rosemarie Nelson, Lucien W. Roberts, Elizabeth Woodcock, and others as they help improve your medical practice and your bottom line at 

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1. Do you charge a monthly "subscription fee"? If so, how much do you charge?

2. Do you charge a copay for office visits (or simply charge for visits alone, if you don't do a subscription fee)?

3. Do you charge extra for labs, immunizations, and other services as an additional revenue source?

While I cannot expertly give all of the pros and cons of each of these options, I can explain how I decided on the route I took, as well as the consequences, good and bad.

I charge a monthly subscription fee, ranging from $30 to $60 per month based on the age of the patient; that includes a $150 monthly maximum for families. I also have a one-time "registration fee" of $50 per person ($200 family maximum). I do not have any discount for people who pay for the year in advance, nor do I require people to commit to any more than a month at a time.

The main reason I chose this method was to keep it simple and affordable. I want it simple because I am a doctor who does not like accounting: I 

 to chase down money I am owed, nor do I want to refund patients should I somehow not be able to provide the services they have paid for â for example, if my office burns down or I get sick. The amount I charge is aimed at keeping my services affordable for my patients.

 This has really worked quite well. I have a reliable income that has grown each month I've been in practice. The growth of my practice, however, has not been too rapid, nor have I been overwhelmed with workload (so I think the price is not too low). Very few people have left the practice for financial reasons.

I do not charge a copay for visits. When I did the math, the difference between what even a substantial copay would contribute vs. no copay at all was quite small. The vast bulk of my income comes from monthly payments â regardless of copays. I also felt that charging a copay would make my patients avoid care they needed, which sabotages my "high access" model.

 I was afraid that patients would abuse the no additional cost, open access, but currently (at 400 patients and growing) that has not been the case. The reality is that most people 

 going to the doctor, and the majority of their problems can be managed via telephone or secure messaging, so my office is often empty. Because of the monthly fees, I earn just as much with an empty office as I do with a full one. That's a very welcome change.

I do everything possible to give services at, or near, cost to my patients. Immunizations, labs, office tests, and procedures are not marked up. I do this partly because, in the big picture, the income from them would be insignificant; but more importantly, I want to give my patients services they can't get elsewhere. I want to raise the cost for them to leave my practice â so they will keep paying me their monthly payment.

 The largest benefit is that my patients trust me much more than they did in my old practice. They know I am not going to "nickel and dime" them for every little additional service. Plus, the drop-out rate in my practice has been very low; indicating that I am giving my patients enough value to keep them paying me each month.

While I am still not certain of exact numbers, I am very optimistic about the straight, monthly fee-payment model I've chosen. I have a predictable monthly income (regardless of my patient volume). And more importantly, I am no longer dependent on sickness or clinical problems to get paid. I can now focus on treating patient problems when they are small and using education to help my patients spend their time where they want to be: away from the doctor's office.

is board-certified in internal medicine and pediatrics, practices in Augusta, Ga. In October, 2012, he left his "traditional" primary-care practice and opened a cash-only "direct care" practice. Dr. Lamberts can be reached at 

While the decision to change to a direct-pay practice can be the most difficult one a physician can make, there is a second decision that is nearly as difficult: What to charge for services. 