From DPC

Declaring Independence: Creating a Nurse-Run Practice

By Tanya Spoon, ARNP, DNP

This article was originally printed in the May 2017 issue of Voice of Nursing Leadership

In an issue focused on the value of nursing, the story of an independent nurse-run primary care practice is worth exploring and perhaps a roadmap to the future.  Tanya Spoon, ARNP, DNP, founder and owner of The Manette Clinic, Bremerton, Wash., tells the story of how she established and grew her own practice.  In her home state of Washington, practice laws allow her to operate the clinic without physician supervision.

I was lucky.  I got a job before I graduated with a family nurse practitioner degree in 2006.  I worked with an older doctor who wanted to include an NP as part of his practice.  In the beginning, I had total freedom to see two or 10 people a day.  It was a great way to learn how to practice primary care.  Even though I had been an RN since 1996, I was reentering nursing as a novice.  It was an amazing time.  I felt like I had reached my goal of independence practice, and that people were really coming to see me, as the physician already had a full schedule.  But health care was changing and I was becoming proficient in my practice.  This meant I could see more and more patients each day.  Within two years, I was treating up to 28 patients a day; my patients felt cared for even in an 8- to 10-minute appointment.  I learned to quickly and confidently diagnose and treat.  Everything was going well, right?  Wrong.  I was growing really tiered, and felt like I was on a treadmill all day.  I would go in at 7:30 a.m. and leave at 7 p.m.  My workouts had all but stopped, I was eating my lunch as I charted, surviving on coffee and sugar.  I was doing well financially, but I knew I couldn’t keep this up.  I wanted to continue to care about each patient as a unique individual and not just rush a patient through, but I felt like this is what I was doing just to keep up with pace.  What started as an amazing opportunity was becoming a burden.  By autumn 2014, it became clear that I had to change the way I was practicing primary care.

Finding a path

I started to research other options.  The doctor who had originally hired me was nearing retirement, so my timing was important.  A large hospital system was moving into our community, buying up practices and I knew I wouldn’t be a fit for the larger organization.  I also knew that I wanted to remain authentic in the way I believed I should care for my patients.  This is when I found Direct Primary Care (DPC), which is a care delivery and payment model.  DPC is membership-based primary care, no insurance billing, just a monthly fee for unlimited primary care.  I started calling different clinics that were involved in DPC.  I actually found the cell phone number of a doctor in Wichita, Kan. and cold-called him.  Josh Umbehr is a Kansas physician who started a clinic called Atlas MD.  He answered his phone and was delighted to answer all of my questions.  Another doctor in Seattle, Garrison Bliss, generously gave me two hours of phone time on a Saturday morning.  I was amazed that they were as excited as I was about the prospect of my own clinic.  After a series of phone calls and research, I decided this was the way I could continue as an NP.  But I was wrestling with this: I would be the first DPC clinic in my community and I’m a NP.  Would people come?

Challenges to overcome

I experienced some roadblocks on my journey.  I started talking to people about this unique style of primary care.  Most people smiled at first, then got a glazed look on their faces as I explained what I wanted to do.  I would incorporate “personalized primary health care for families” as my tag line.  Personalized to me would mean minimum 30-minute appointments and home visits if needed.  My patients also would have my cell phone number and could call or text me at any time.  I didn’t want multi-phones, and I needed a staff that was sold on this new idea.  I wanted my patients to feel like they were stepping back in time, and I was excited about the possibilities of using an old fashioned way to provide care.  It would mean, however, that I would keep a limited number on my patient roster and focus on taking really good care of them.  This was frightening, but exactly the type of clinician I wanted to be.

The biggest roadblock was Medicare.  Some of my neediest patients were Medicare beneficiaries and it was impossible to explain this idea of paying a membership fee for their primary care when they already had Medicare.  Some of my patients were in memory care and I already provided home visits for them and wanted to continue.  Most were on such a limited income that they would not be able to afford the membership fee.  I had to make the decision to keep or give up my Medicare provider number.  Many DPC providers give up their Medicare number because it simplifies things.  In my community, very few places would take these patients and so I would be leaving a couple hundred Medicare patients without care.  I had cared for them for eight years and the doctor I worked with had them for many years prior to that.  Because of this, I decided to keep my Medicare number and those Medicare patients who wanted to stay with us at my new clinic.  It made my idea of a simple membership practice a little more complicated – the clinic would have to accommodate two types of payment – but I felt like it was the right thing to do for my patient population.  What I didn’t know is that the assisted living and memory care residential centers had no providers on staff; the residents are not allowed to leave the facilities, so it is difficult for them to get to care appointments.  I am one of two providers in our community that make house calls and this allows me to treat these patients.  What started as a roadblock is becoming a little niche for my clinic, and to top it off, these patients are getting great primary care.

During the weeks that led up to my decision, I was not only seeing 28 to 30 people a day, but also I was researching for hours about what this practice would look like, writing a business plan and telling people about the plans for my new practice.  I also was trying to grasp that I wouldn’t have a paycheck for a number of months and what that meant for me and my family.  In addition, I was trying to make the case to my friends and family that I wasn’t going to work myself into the ground, but would actually have a better work/life balance.

Roadblocks such as funding, location and finding a lawyer were all very nerve wracking to overcome.  During the winter of 2014-2015, I was grappling with paying for my malpractice insurance, license renewal and office space – all of which used to be covered by my employer.  To help finance the venture, I took on a part-time teaching job and refinanced my house.  It was a very busy time.

Opening the practice

We opened in September 2015, with just over 100 patients.  The staff was lean – just me and a receptionist.  The office manager would start a couple months later.  The construction on the space we were renting wasn’t even complete, but each day the interior started looking more like a medical office and less like a strip mall location.  the local paper published a story on the clinic the week before I opened.  People started calling.  After four months of seeing patients we were in the black and I actually saw a small pay check.  At our one-year mark, we were at 500 patients, and at the 18-month mark we are close to 800.  I’ve brought in a couple of amazing NPs to help me part time and the physician I worked with before comes in 10 hours a week in his retirement.

Things are moving forward and in March 2017, we added a full-time physician who hopes to become a partner.  This is definitely the next chapter and will be important for the clinic’s success.

This experience taught me that the only real roadblock was my own lack of confidence and creativity, but I overcame that hurdle.  I have accomplished something truly amazing and now can give my patients – and myself – amazing care, spending time caring for and teaching patients in a unique way.  And that’s a practice I can be proud of.

Tanya Spoon, ARNP, DNP is founder and owner of The Manette Clinic in Bremerton, Wash.  For more information about the practice, visit the clinic’s website at




A Cost-Effective Alternative to Expensive Health Insurance

The Manette Clinic has partnered with Liberty Health Share to offer Liberty Direct, a cost-effective alternative to expensive health insurance.  Rather than health insurance, Liberty Direct is a medical cost-sharing program for individuals, families, and even employers.  Membership with Liberty Direct is a government-recognized alternative to purchasing health insurance, meaning that members with Liberty Direct do not have to pay the ACA tax penalty.

Patients find this to be incredibly valuable for two important reasons:

1.The monthly savings are very significant for a lot of people.The monthly costs are easy to understand, so you can quickly determine if you or your family would save money with this program (see chart below).



2.Out of your Monthly Share with Liberty Direct, Liberty Direct will send The Manette Clinic payment towards your membership (see chart below).  This means your monthly membership fees with The Manette Clinic will be paid off or greatly reduced.


To learn more about Liberty Direct,

Contact Liberty Direct directly via their website at: or give them a call: (800) 991-4885


Contact The Manette Clinic via email: or give us a call: (360) 621-2696

Open Enrollment Season… Consider This Before Changing Health Plans

LISA WELLS: Open Enrollment Season … Consider This Before Changing Health Plans

By Lisa Wells, Special Contributor,Courtesy of Wheel:Life

SEPTEMBER 4, 2015 – 

With open enrollment for health insurance starting in November 2015, it’s important to evaluate your current benefits to decide whether or not your plan is working for you. Looking for another plan that better fits your budget? You may want to research other policies. Before changing your current health insurance coverage though, consider these factors below.

Do Your Research

You can’t just take a friend or family member’s word for it when it comes to selecting the right health insurance. Every health insurer is going to have a different policy, different prescription coverage, and different deductible.

It’s crucial that when considering switching providers for you to conduct your own research. Look up information online, or call several providers to get a personalized quote. When you do this, you’re going to need to know what your deductible will be, as well as an idea about the kind of out-of-pocket expenses you would be looking at if you were to go with that company’s coverage plan.


OPEN ENROLLMENT Season in DPC … Here’s everything you need to know

Even if you don’t think you need to change providers, go back and review your current coverage and see what you spent money on in the previous year. It may surprise you, and encourage you to make changes for the upcoming year, especially if you’re expecting major life changes such as a new member of the family or a new job. When you have an idea about what your future costs may be, you’ll have a better idea of which plan is going to be most cost-effective for you.

Also, check your medical insurance premiums and combine them to determine whether or not the expense adds up to what you actually had in medical expenses the previous year. If you used medical services often, it may be a better decision to consider a plan that has a higher premium, and a lower out-of-pocket cost.

If you use monthly medical supplies, contact your current supplier and make sure they are in-network with your new plan BEFORE you change.  Failure to do so may cause an interruption or out-of-pocket expense for your medical supplies like catheters or continence care products.

Doing the research may be tedious, but once you have a better understanding of the current plans available, you’ll have a better idea of what questions to ask.

August-September Is Open Enrollment for DPC: ‘The autumn period when many with employer-sponsored health insurance decide which plan they will choose for the coming year …’ say DPC Journal Physican sources.

Ask The Right Questions

Many insurance companies have a cap on out-of-pocket expenses for the customer. Not all providers have an out-of-pocket cap, and not many providers will tell you this until you’re already in debt. In most cases, the lower the cost of the policy, the higher the cap will be.

If you develop a disease or more advanced condition later on that requires a costly medication, then you’re going to want to be prepared. In order to be prepared, consult providers about their prescription coverage both for any current medications you’re on as well as for any you may have to use in the future, and talk to them about long-term coverage, in case you were to develop any symptoms that required an expensive medication.

People often forget that just because they have insurance, it doesn’t mean they’re covered across the globe. Those who travel often, or even just once a year overseas, are going to want a policy that would cover medical expenses abroad. You never know when you’ll need medical attention, or what part of the world you’ll be in when you do.

In exploring various providers, the information can be overwhelming, and can cause information overload and anxiety. Health insurance is complex, so it’s important you ask a lot of questions, and make notes about each company you speak with, so that you can keep up with who offers what.

Click here for the 9 questions you should ask each insurance provider before you commit!

Note: This article should be considered as informational only and not construed as medical or financial advice.

Typical Services Inside A DPC Office

When using a Direct Primary Care Doctor who includes a monthly, quarterly or annual membership plan, most practices will provide all patients with:

Unlimited Access to your doctor or doctor’s office.

Many DPC doctors and offices can provide same or next-day care for urgent medical issues such as sprains, respiratory illnesses, cuts requiring stitches, urinary tract infections, fractures, and more.  If you are not sure whether your condition is something your paricular DPC doctor/office can take care of, we recommend you call and they will help direct you to the best place to get it addressed.

Unhurried Appointments with doctors who focus completely on your health and well-being.

Your visits may include extended consultations and personalized coaching to create positive lifestyle changes such as weight loss, smoking cessation, and stress management.

LAB TESTS –  Many DPC doctors/offices offer some basic onsite laboratory testing at no additional charge (such as pregnancy testing, strep throat testing, HIV screening, and others).  For other tests, your DPC doctor/office may send samples to their partner laboratories for processing or refer you to a local laboratory for testing, many times at a significantly reduced/discounted rate.  If you would like to use your insurance to pay for your tests, many 

DPC doctors will forward your information to the laboratory to be billed directly to your plan.  

Check with your DPC doctor/office and ask if they provide this service. IMPORTANT: If you would like to take advantage of discounted cash pricing, many DPC doctors/office often pre-negotiate discounts of up to 75% off of regular pricing for specific tests. Ask your physician/office about this. All testing and any associated costs should be discussed with you prior to ordering and processing any tests.

Receive health care support in person, by phone, or by email.

In the case of serious illness requiring emergency or hospital care, your DPC doctor can typically communicate with the hospital, send over any relevant records, and coordinate your care during and after discharge.  If you have a serious emergency requiring immediate medical attention, call 911 and then either call your DPC doctors/office or have the hospital personnel call them to let them know so they can participate in your care while staying at the hospital. 

 Most DPC doctors/offices can coordinate hospital and emergency care remotely, working with other doctors and care providers over the phone and touching base with you and/or your family members.  Some DPC doctors maintain hospital privileges and provide direct, bedside care and coordination at the local hospitals in and around their local practice. Check with your physician as to which hospital he/she may admit you to in the future.

Should you need to see a specialist, your DPC provider may coordinate your referral, communicate with your specialist, and work with you to make decisions about and follow through with your care plan.

No co-payments, co-insurance, or deductibles (Note: There are many practice/delivery models used by physicians at these offices. Please check with your physician/doctor’s office and ask them about this.)

Help in monitoring and managing chronic conditions such as high blood pressure, diabetes, high cholesterol, asthma, arthritis, etc.

No long-term contracts when joining

No restrictions based on age or pre-existing conditions—everyone is welcome

Overall Benefits Also Include:

Uncompromising focus on personalized, high-quality primary care

Convenient in clinic, phone and electronic access

Qualified doctors, nurses, and medical teams providing comprehensive primary care services

Tanya Spoon

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