This is part 3 of a 3-part series regarding non-DPC services for your DPC practice. In Part 1 of the series, “Why Adding Non-DPC Services is a Great Way to Build or Grow Your DPC Practice,” I described some of the reasons why this might be a good idea (additional revenue streams, limiting panel size, keeping things interesting). In Part 2, “How to Add Non-DPC Services to Your DPC Practice” , I described some of the types on non-DPC services (extension of primary care services, alternative medicine, new/non-covered services, and products), mentioned several examples of our DPC colleagues that are doing this, and listed some logistical considerations. In this third and final installment, I will discuss my own experience with adding non-DPC services to my DPC, so you can share in my successes as well as learn from my mistakes.
The one piece of advice I would have to any DPC doctor considering adding non-DPC services is to be open to opportunities that present themselves, while also evaluating things carefully before proceeding. None of the three non-DPC services I have incorporated into my practice were things I proactively looked into. All three were opportunities that presented themselves, which I was fortunately open to. Two are successful, one not so much, the latter of which I wish had considered more carefully.
One of the first non-DPC services I tried to add was aesthetics. While I was able to retain some previous patients in my new practice in the first two months, acquisition of new patients following that was extremely slow. Having started my DPC later in my career with two kids who would soon need college tuition, I could not wait 3-5 years to become profitable. Thus, I started looking at other ways to generate revenue while my DPC grew including telemedicine, medical weight management, and legal work; none of which seemed to be a great option for me. One morning a brochure for aesthetics showed up in my mail. While I might normally have trashed this immediately, my desire to try additional services made me take a look. Within a day or so, a representative from the same company called on me directly. While I understood that these companies use heavy handed sales tactics (drug reps have nothing on these guys), I did my own research and the numbers seemed to make sense. They also offered a lot of incentives including a free website with SEO for a year (which I still use). While PCP’s are able to do fillers and injectables (Botox) for little upfront cost, I am an internist who doesn’t like needles. Unfortunately, most other aesthetic procedures require purchasing a large machine at a huge cost, and these aggressive companies will dazzle you with numbers that are quite convincing. While I do believe these high-priced machines can work in DPC, there are a few caveats. First, regardless of your marketing and SEO, unless you spend a lot on advertising, most referrals will come internally, i.e. from your own patients. Thus, this might help and established DPC, but not a new one like mine. Second, with aesthetics, offering more than one service is usually best, i.e. Botox and fillers, plus a laser treatment; so having just one service did not help me. Ultimately, this service was not very successful and I lost a significant amount of money on purchasing a machine, but also view this as loan that helped me sustain my practice. (If anyone is interested in starting aesthetics and wants to purchase a lightly used body sculpting machine for almost nothing, please contact me).
The second non-DPC service I added was medical cannabis. This was not something that was even remotely on my radar screen. However, my state had recently legalized medical cannabis, and a new medical cannabis dispensary moved into my medical building. I spoke with the owners before the dispensary opened, and they informed me that few doctors were registered to certify patients. (I later realized that one of the reasons for this is because insurance-based physicians have a hard time charging patients extra for cannabis certifications as it might violate their contracts- making this ideal for non-insurance based DPC). Being a new practice with few patients, lots of time, and overhead that was not being covered by patient revenue; I figured what would be the harm if the dispensary sent up a few patients for me to certify. While I was initially skeptical about doing this, and worried that people were coming me for a legal excuse to use pot; I quickly discovered that the patients coming to me were really sick (metastatic cancer, opioid addiction) and that cannabis really helped them. I decided that if I was going to certify patients, I had to really educate myself on this, which was harder than I had anticipated. Yet, these efforts eventually led to the publication of a book (available on Amazon). Though my practice has grown to the point that I no longer need to do cannabis certifications, I continue to do this because I really enjoy it. As one of the few physicians in my area that openly certifies patients for medical cannabis as part of my practice, as well as being a book author, medical cannabis allows me to be a specialist/expert and PCP at the same time. At least in my case, the variety and intellectual stimulation that comes from adding non-DPC service, may be just as valuable as the additional revenue it brings.
The third non-DPC service I offer is administration of nasal esketamine (Spravato). Again, this is something I was not looking for, but stumbled into. I had to get my DPC up and running quicky, and I was very lucky to find a great space that was ready to go, ; however, it was a tiny bit bigger than I needed, with an extra unused exam room. I thought about subletting to a therapist or nutritionist, and even looked into clinical trials, but nothing really stuck. During some early networking, I connected with a psychiatrist who was doing IV ketamine treatments for treatment resistant depression. Ketamine at low doses can be highly effective for treatment resistant depression, is safe (anesthetic used in kids), and has been around for a long time. However, while generic, ketamine is not FDA approved for this use, and therefore insurance will not cover the cost. Most ketamine clinics charge around $700 per IV treatment which are generally given weekly. This psychiatrist told me that an FDA approved nose spray would soon be on the market. I had mentioned this to a patient of mine who had previously told me that IV ketamine was too expensive. Over a year later, he reminded me about this, and when I looked it up, Spravato (nasal esketamine) was FDA approved and available. Spravato is a controlled substance and available through a REMS program, so providers must register in order to give it to patients. However, after I registered for my patient, the next day 2 non-member patients called asking about Spravato. It turned out that when I registered for my patient, I had signed up to be a treatment center and was listed on the company’s website. Spravato is not available in pharmacies and comes directly to the doctor. Patients on Spravato must be observed in the office for 2 hours with blood pressure checks. Since I had an extra room and a not too busy staff person, this seemed ideal for my practice. The medication itself is usually covered by the patient’s insurance. Since I don’t take insurance, I charge patients fee for service for the treatments, and generate an invoice for them to submit to insurance for reimbursement, which is usually successful. Spravato has become an interesting and excellent non-DPC service for my practice. Most psychiatrists in my area are solo practitioners who do not have the space or staff to administer Spravato, so I am essentially offering a service to them and their patients. I have also been extremely impressed with the results. Most patients are severely depressed and have tried everything, and Spravato has been one of the only treatments that has helped.
In summary, I believe adding non-DPC services to my practice has been very beneficial-even aesthetics which I lost a significant amount of money on. These services allowed me to generate revenue while my practice was growing, and currently allow me to limit my panel size now that my practice is stable. Given that medical cannabis and ketamine are less conventional approaches to mental health conditions, these non-DPC services also allow for opportunities to do some branding of my practice (if and when psilocybin becomes legal, I am seriously considering adding this as another non-DPC service). While I never planned to write a book or do a ton of speaking to the local community, adding medical cannabis to my practice allowed me to do this, which led not only to referrals for cannabis patients, but also new DPC member patients. All of these happened because I was open to opportunities which presented themselves. In retrospect, I wish I had been a little more careful before starting up with aesthetics. However, in any business you are going to have successes and failures, and failures are just opportunities to learn and grow.
Dr. Matthew Mintz is an Internal Medicine and Primary Care physician, whose concierge-style DPC offers non-DPC services including Spravato (nasal esketamine), medical cannabis, and TruSculpt3D. Dr. Mintz’ website is www.drmintz.com and medical cannabis site (different for legal reasons) is www.mdcannabisdoc.com.