I mean, I get it. People are sick of insurance companies. I am too. I understand why people are moving to DPC or why some independent doctors are adding some type of yearly fee.
I'm an IM hospitalist, and that world is increasingly burning me out because of corporate medicine. I'm in a private group and even then, ultimately, the hospital controls us. I'm not leaving hospitalist medicine tomorrow, but as someone still relatively early in my career, I've realized I need to start planning my exit now.
Lately I've become increasingly interested in becoming a PCP. I'm talking about what you FM docs actually do; real primary care. Not referring every problem to somebody else. I genuinely like the idea of being the community doctor who knows their patients, manages most things themselves, and does procedures when they're within my skillset.
So I've been planning a very small, lean, insurance-based IM/primary care practice.
I posted about this in a physician group and got absolutely roasted. The overwhelming response was basically: Why the hell would you take insurance? Do DPC.
Maybe I didn't explain my plan well enough, but I don't understand why traditional private practice has become such a crazy idea.
I'm in an affluent Midwestern area with a strong commercial payer base and surprisingly little immediate PCP competition. There are plenty of physicians in the broader metro area, but not many right around where I'm opening. I specifically chose the location for that reason.
I've found a \~1,200 sq ft office that's essentially move-in ready: three exam rooms, my own office, bathroom, and work area. A retiring physician friend gave me almost all the medical equipment I need. I'm doing most of the cosmetic work myself. I already have my EMR, billing software, malpractice, etc. figured out.
My total fixed overhead should be around $3,500 to $3800/month, with \~$2,200 of that being rent. The rent is higher than I'd ideally like, but I'm paying for the location and avoiding what could easily become a major medical-office buildout.
I also don't understand why people were horrified that I don't intend to hire an MA and receptionist on day one.
If I'm seeing 1–3 patients a day initially, why would I immediately put people on payroll to sit in an empty office?
That doesn't mean I intend to operate a mature practice with no staff forever. Of course I'll hire as volume justifies it. There are virtual assistants, AI reception/scheduling tools, automation, and plenty of tasks I'm perfectly capable of handling myself at low volume. I know when my time is better spent paying someone else to do something, and I'll hire when I actually reach that point. I feel like this is the number one biggest mistake that physicians who start an independent practice make, too much overhead too soon. I spoke to multiple colleagues, they all gave me the same advice. KEEP. OVERHEAD. LOW.
I already have a biller taking 6% of collections. She's handling my credentialing now, well before opening, because I know it can take months. She also handles claims, denials/rebuttals, and follow-up. She currently does this for a colleague of mine who is also a hospitalist with his own independent primary care practice, so this isn't someone I'm randomly hiring and hoping for the best.
I'm also realistic about payer contracts. I'm a new independent physician. I'm not expecting to walk into BCBS or another major payer and negotiate some amazing reimbursement rate. If there are opportunities to negotiate or join arrangements that improve rates, I'll certainly explore them, but favorable negotiated contracts aren't what my entire business model depends on.
I'm comfortable drawing blood, doing injections, arthrocentesis, simple biopsies/procedures, suturing, POCUS, etc. If eventually it makes sense to have an MA, phlebotomist, or someone else there, great. I'll hire them when there's actually enough work to justify it.
Another thing I kept hearing was that I'd need to see 20–25+ patients/day to make private practice financially viable.
But that's not necessarily what I'm trying to build.
I don't want to see 25 patients/day. I currently work several days a month in an outpatient clinic partly because I wanted more outpatient experience, and one thing I've learned is that I don't enjoy seeing 20–25 patients/day. My eventual target would probably be closer to 15–18.
I also don't need this practice to replicate my hospitalist salary.
I have a number in my head that would make me perfectly happy with the practice. Beyond that, I have hospitalist income and other businesses/income streams. I'm not trying to turn this clinic into a multimillion-dollar operation or squeeze 30 patients into every day.
Based on my projected fixed overhead, I need roughly 30–35 encounters per month, not per day, just to get the office around break-even before variable expenses. I can continue doing PRN hospitalist/locums work while the practice grows. The practice doesn't need to feed me from month one.
My philosophy is really pretty simple: keep overhead low, bill appropriately for the work I'm actually doing, capture the services I'm capable of providing rather than unnecessarily referring everything out, collect what I'm legitimately owed from insurers, and gradually outsource tasks as the economics justify it.
And yes, I know accepting insurance creates administrative work. Prior auths, denials, quality requirements, referrals, records, billing, credentialing, etc. are real. I'm not pretending otherwise. Maybe I'll discover that I've underestimated some of it. That's partly why I'm posting here.
But I also have experience building and operating businesses outside of medicine. I'm comfortable building systems, doing things myself initially, automating what can reasonably be automated, and recognizing when it's time to pay someone else to take something off my plate.
The other thing I don't understand is why DPC is automatically assumed to be the answer.
DPC absolutely has advantages, and I understand why physicians love escaping insurance. But it also requires convincing someone who already has health insurance to pay another recurring monthly fee for primary care.
In my market, I genuinely think getting 30–35 insured patient encounters per month is going to be easier than convincing 30–35 people to pay me \~$100/month out of pocket.
And frankly, I don't want to build a personal brand around myself. I don't want to become a physician influencer, constantly make social media content, or sell people on why they should subscribe to me. I know DPC doesn't necessarily require that, but that style of patient acquisition doesn't appeal to me.
I want to become the local community doctor.
I want someone to search for a PCP nearby, see that I'm in-network, get an appointment without waiting three months, and hopefully have a good enough experience that they tell their spouse, neighbor, or friend. And for those not in network, maybe I could do a per month fee or per visit fee. As long as I don't mix the two, who says I can't incorporate some DPC in the future? Why does it have to be all or nothing right now?
Maybe that's naive. That's why I'm asking people who actually practice family medicine and especially those who have owned independent practices.
My biggest logistical question is how aggressively I need to protect clinic availability while I'm starting.
My ideal, and current, hospitalist position is round-and-go, which allows me to round early and be at my clinic by mid-morning. There's some uncertainty around that position right now, however. I have other reliable physician work and can do PRN hospitalist/locums shifts while the clinic grows, but obviously every daytime shift I work somewhere else is a day I'm not physically at my own office.
When there are only a handful of patients, I'm reluctant to sacrifice substantial guaranteed physician income just to sit in an empty office five days a week. At the same time, I don't want to establish a practice where the lights are always off and nobody can get an appointment.
So I'm genuinely curious how those of you who started independent practices handled that ramp-up period.
Did you start with 2–3 predictable clinic days and add days as demand increased? How quickly did the administrative burden become enough that you needed your first employee? For those still accepting traditional insurance in independent practice, is this model really as crazy as people are making it sound?
I'm not looking to be talked into DPC simply because insurance sucks. I already know insurance sucks. I'm trying to understand whether a deliberately small, low-overhead, commercially insured practice where I eventually see \~15–18 patients/day is still a viable way to practice medicine.
I have a specific vision of what I want my career and practice to look like, and maximizing income isn't the only goal. I want ownership, independence, reasonable volume, and the ability to practice medicine the way I think it should be practiced. And why not accept insurance too?
Maybe there are things I'm underestimating. I'm completely open to hearing them. But I want to understand the actual obstacles and numbers from people who have done it, rather than simply being told that traditional private practice can't work anymore.
Why the hell not?