10 Steps to Start Your Direct Specialty Care Practice
If you are wondering how to start a direct specialty care practice, the short version is this: about a year, ten clear steps, and no MBA required.
I know because I did it as a physician in the traditional system, seeing 25 to 28 patients a day. I spent hours writing notes to satisfy the right billing codes, and more hours calling insurance companies to justify the care I had already decided my patients needed.
The reimbursements kept shrinking while the paperwork kept growing, and every year I was asked to do more for less. I was burned out, and I know now that I was not alone. Like a lot of my colleagues, I kept asking myself a quiet question: is this the medicine I prepared for?
If you are reading this at the end of another exhausting day, dreading the inbox, the denials, and the paperwork that never ends, I want you to know that the feeling is not weakness and it is not permanent.
It is a rational response to a system that put a billing code between you and your patient. You do not have to keep trading your health and your judgment for a reimbursement rate someone else decided. Other specialists have already reclaimed the soul of their medicine by walking away from it.
Quick answer: You can start a direct specialty care practice in about a year. The path has ten steps: understand the model, plan the finances, handle the legal setup, choose telemedicine or local or both, plan your transition, build a website, choose an EMR, set up direct contracting with labs and imaging, choose a pricing model, and decide on Medicare. None of it requires an MBA, and none of it has to be done alone.
Complaining was not going to help.
So I took action, and in less than a year, I started my direct specialty care practice. Here are the ten steps I would give any specialist considering the same path. You do not have to walk them alone. If you want the bigger picture first, start with what direct specialty care is and why it is emerging now.
How to start a direct specialty care practice: the 10 steps at a glance
Here is the full path in one view. Each step is explained below.
- Understand the direct care concept
- Get clear on the finances
- Handle the legal side
- Decide: telemedicine, local, or both
- Plan your transition
- Build a website
- Choose your EMR
- Set up direct contracting
- Choose your pricing model
- Decide on Medicare
You can work through these alone or learn how to start a direct specialty care practice alongside physicians who have already done so. Either way, the steps are the same.
1. Understand the direct care concept
About a decade ago, a few primary care physicians rebuilt their relationship with patients through direct primary care: remove the insurance company, contract directly, charge a fair fee. Specialists hesitated for years, afraid of losing the referral system. But in a free market, patients search, compare, and pay for the care they need. The result of going direct is less documentation and billing burden, mutual accountability between the physician and the patient, and transparent pricing.
2. Get clear on the finances
Physicians often assume they are not good enough to run a business. I disagree. There is a learning curve, the same as there was for medicine. Build a tentative business plan that accounts for legal services, office expenses, staffing (a local versus a virtual medical assistant), your EMR, phone and fax, marketing, and accounting. You will make mistakes and invest money.
Those investments go into your company. If it helps to hear the business side from someone who built a direct practice from scratch, this conversation walks through it.
3. Handle the legal side
Find a health lawyer familiar with the direct care concept. They will help you form your business entity, build your patient agreement, the Direct Care Contract, and review your website content. This is the legal spine of the practice. Do not improvise it.
4. Decide: telemedicine, local, or both
A local practice and a telemedicine practice require different planning, and many physicians run both, offering local visits with telemedicine as a perk. If you go telemedicine-first across multiple states, get licensed where demand for your specialty is highest. Licensing is expensive and slow, so be strategic about it.
5. Plan your transition
If you already have an insurance-based practice, analyze your best and worst payers, and start by gradually canceling the contracts that hurt you most. If you are building new, begin educating patients about direct care now, open a registration page to collect emails, and stay open to locums, moonlighting, or independent medical review work while you build your panel.
6. Build a website
Your website is your property and usually the patient’s first interaction with you. Patients will Google your specialty and see your site before they ever see you. Build it yourself or with a designer, and make sure it clearly explains direct care.
7. Choose your EMR
Pick an electronic medical record where you own your patients’ information. None is perfect. I wanted to reach a chart from anywhere, so I chose a cloud-based system. Common direct-care options include Cerbo, Elation, Practice Fusion, and SigmaMD.
8. Set up direct contracting
This is the step patients feel the most. Contact laboratories, imaging centers, and independent pharmacies and ask for “client” prices, the discounted rates between your practice and those facilities. You will be surprised how low they go, sometimes ten times lower than insurance-negotiated rates. Every middleman you remove is money the patient keeps, and transparency they remember.
9. Choose your pricing model
Fee-for-service, bundled pricing, or a membership model for chronic management, or a combination. The right approach depends on your specialty, your time, and your local market. Whatever model you choose, keep every price transparent and known before care, so patients never face a copay or a surprise bill.
10. Decide on Medicare
You have options. Keep seeing Medicare patients under contract and submit billing to Medicare, or opt out and charge transparent cash prices. Most direct care physicians opt out, for simplicity and to avoid running two billing systems at once. Opt-out lasts two years and renews.
The step that is not on the list
During this journey, you will learn, evolve, and reconnect with fellow physicians. That last part is the one that changes everything. The burnout that felt permanent starts to lift the moment you stop fighting a system alone and stand next to people who left it and came out whole. Every question above, the entity, the contract, the licensing, the pricing, the labs, someone in this field has already answered. You can spend a year solving it alone at your kitchen table, or you can borrow the answers from people who have built exactly this, like the anesthesiologist who left insurance to build Renovo Health.
That is what the DSC Alliance is. The contracts, the pricing models, the community, and a directory built so patients can actually find you, on Google and in the AI tools they now ask first. Join the movement, regain hope, and start practicing medicine for the benefit of your patients. Together, we make the whole field remarkable and make each other findable.
Medicine the way it was meant to be. Built in ten steps, and built together.
We built this, and now it has a home.
For years, there was no specialist-specific home for direct care.
So we built one.
Explore the new platform at dscalliance.org: the full webinar library, the DSC Starter Course, the monthly newsletter, a private community of specialists, and a national directory built so patients can actually find you.
This is the opportunity, and the door is open. Founding membership is free for your first 12 months for verified physicians, with your founding price locked for life. Come be part of our family before the founding round closes on December 31.
Create your free founding account → dscalliance.org/membership
Key takeaways
- A specialist can start a direct specialty care practice in about a year, and it does not require a business degree.
- The legal spine matters: form the entity and build the Direct Care Contract with a health lawyer who knows the model.
- Direct contracting with labs, imaging, and pharmacies for “client” prices is where patients see the biggest savings, sometimes ten times lower than insurance rates.
- Choose a pricing model that fits your specialty, whether fee-for-service, bundled pricing, or memberships for chronic management, and keep every price transparent and known before care.
- Most direct care physicians opt out of Medicare for simplicity, a decision that lasts two years and renews.
- Every step has already been solved by someone in the field, which is what the DSC Alliance is for.
Frequently asked questions
How long does it take to start a direct specialty care practice? It can be done in about a year. Dr. Girnita started hers in less than a year while still working, by taking the steps in order and borrowing answers from physicians who had already built direct practices.
Do I have to opt out of Medicare to practice direct specialty care? No. You can keep seeing Medicare patients under contract and submit billing to Medicare, or opt out and charge transparent cash prices. Most direct care physicians opt out for simplicity, and the opt-out lasts two years and renews.
Should I run a telemedicine practice, a local practice, or both? Many physicians offer both, with local visits and telemedicine as a perk. If you go telemedicine-first across states, get licensed where demand for your specialty is highest, because licensing is slow and expensive.
How do specialists set prices in direct care? Common models include fee-for-service, bundled pricing, and membership-based models for chronic management. The right approach depends on your specialty, your time, and your local market. What matters most is transparency: patients should know the cost before care, with no copays or surprise bills.
Do I need a lawyer to start a direct specialty care practice? Yes. A health lawyer familiar with direct care helps you form your business entity, build the Direct Care Contract, and review your website. This legal setup is the spine of the practice and should not be improvised.
How much does it cost to start a direct specialty care practice? Startup costs vary, but plan for legal setup, business registration, an EMR subscription, a website, phone and fax, basic marketing, and accounting. Many specialists start lean with telemedicine and a virtual assistant, then add local space as the panel grows.
Can direct specialty care help with physician burnout? For many specialists, yes. Burnout is often driven by shrinking reimbursements, endless paperwork, and documentation built for billing rather than care. Direct specialty care removes the insurer from the visit, so you can set your own schedule and prices and spend your time on patients rather than denials. It is not a cure for every cause of burnout, but it returns control that the insurance system takes away.
How does the DSC Alliance help me launch? The Alliance provides contracts, pricing expertise, a community, and a national directory so patients can find you. It exists so that specialists can borrow proven answers instead of solving every step on their own.
About the author
Dr. Diana Girnita, MD, PhD, is a rheumatologist, the founder of Rheumatologist OnCall, and co-founder of the Direct Specialty Care Alliance. She completed a PhD in immunology and transplant immunology, trained at Harvard University and the University of Cincinnati, and is the author of two books on autoimmune disease and nutrition. She built the DSC Alliance so no specialist has to leave the insurance system alone.
Ready to practice medicine the way it was meant to be? Join the DSC movement at dscalliance.org.
