You're probably going over the pros and cons of direct primary care (DPC) if you're ready to escape the hassle of dealing with insurance providers and low reimbursement rates. Direct primary care is a growing trend that swaps the traditional insurance-based system with a membership model.

Patients pay a flat monthly fee and, in return, get personalized care, shorter waiting periods for appointments, and direct access to their physicians.

However, while direct primary care can be equally beneficial for patients and physicians, it's far from perfect. While many hail DPC as the solution to insurance providers habitually obstructing patients' access to the best care possible, some physicians raise concerns regarding its accessibility. 

This article will explore the pros and cons of the direct primary care model, exploring its benefits and drawbacks for patients and providers alike. You'll have all the knowledge you need to decide if direct primary care is worth it for you or your practice by the time you're done reading this article. 

Exploring the pros and cons of direct primary care

Let's start with the basics. Direct primary care is a healthcare model that prioritizes simplicity, transparency, and efficiency. Patients pay a monthly subscription fee instead of a co-pay while the office bills their insurance providers. 

Healthcare models such as subscription-based, cash-based, concierge, and direct primary care can be unclear. Some descriptions portray direct primary care and concierge care as using a flat-rate subscription fee model with visits built-in; however, other descriptions portray these models as using a base subscription fee model with visits charged as additional charges. 

Physicians who want to open their own clinics should determine the best approach by collecting financial data and creating projections for multiple hypothetical business models. 

A common grievance in primary care is that many physicians work outside the consultation room, such as in remote care management and fielding portal messages. However, most clinics bill insurance companies only for visits themselves, which are already reimbursed lower than a specialist visit. 

The goal is always to improve the patient experience and create a low-friction one. Therefore, eliminating the need to pay for each visit could improve the patient experience. 

Time was the most significant barrier patients encountered in one virtual clinic we worked with. This included the time needed for synchronous visits versus a desire to interact more asynchronously and the time spent on payment for each visit. In fact, in this case study, the patients specifically requested to pay cash monthly on auto-pay for the services provided to be more flexible and avoid spending time on payment processing per visit.    

For patients, a break from the traditional healthcare model can often mean unlimited visits, same or next-day scheduling, and direct access to their doctor via phone or email. For physicians, it means spending more time caring for patients and fewer headaches dealing with insurance providers. 

DPC prioritizes physicians building personal relationships with patients, a sharp contrast to traditional healthcare, where patients often report feeling like just another number. Doctors can spend significantly more time with patients—anywhere from 30 to 60 minutes—instead of the standard rushed 10 to 15 minutes in many insurance-based primary care settings. 

The Pros: Benefits of direct primary care

DPC has become a buzzword in healthcare because of the patient-focused approach it offers. Let's examine some of the benefits of direct primary care so you can understand why so many physicians and patients are considering it. 

1. Patients get easier access to healthcare 

Imagine calling, texting, or emailing your doctor anytime without worrying about co-pays or limited office hours. That's one of the most significant advantages of direct primary care for patients. 

Most DPC practices prioritize accessibility, offering same or next-day appointments and sometimes telehealth options. Patients don't have to wait weeks for an appointment with their primary care physicians or spend hours in waiting rooms full of coughing strangers. 

There's also the issue of affordability. The DPC model saves patients from having to guess their healthcare costs and replaces this uncertainty with a predictable monthly membership fee. The flat fee usually includes services like annual physicals, chronic disease management, and essential blood work. 

The direct primary care model provides a lifeline to affordable, high-quality care to individuals and families who don't have insurance. It's widely recognized as an affordable healthcare option because of the quality of care it provides. Some patients shirk at the idea of affordability being linked to paying cash. However, the reality is that patients must also factor in time spent off work trying to access inaccessible clinics, a higher number of emergency room visits known to be associated with low-quality primary care management compared to direct primary care management, and so on which all too often create a costlier situation in the long run than paying upfront for quality primary care. 

2. Patients form stronger relationships with physicians

Doctor-patient interactions in traditional healthcare models frequently feel like a rushed transaction. Patients spend about ten minutes with a doctor, followed by an impersonal prescription. 

This is concerning when prescription errors are known to be one of the most significant contributors to medically inflicted harm in the United States, where medical error is well-known to be a leading cause of death. Common issues are accidental dosage miscalculations. 

One example from recent memory is 3 mg of Lunesta being prescribed three times a day. Here, the slip was that the physician was in a mindset of threes that, thankfully, was caught by the pharmacist but never corrected in medical records. Of course, Lunesta is a sleeping pill. It has been associated with sleepwalking and even sleep-driving if the person is not in bed before taking the medication. This is why more time on patients is needed to allow the physician to focus, double-check, and correct records.

In contrast, DPC allows for more extended visits, typically lasting 30 minutes to an hour. This gives the physician time to actually listen, understand patients' concerns, and address the root cause of their health issues. 

Patients typically report higher satisfaction with the care received under the DPC model because of its more personalized approach. 

Spending more time with patients helps build stronger relationships, leading to better outcomes. This is particularly true for chronic conditions like persistent cerebrospinal fluid (CSF) leaks, which sometimes require ongoing management for years. 

3. Providers gain the freedom to practice medicine on their terms

The financial benefits of direct primary care and the freedom it offers physicians are transformative. Healthcare providers are often frustrated by the administrative burdens of traditional healthcare, such as billing, coding, and dealing with insurance denials. These tasks use up valuable hours that could have been spent with patients. 

The DPC model can help alleviate such frustrations. It allows doctors to focus on providing care to their patients rather than spending half of their days battling insurance companies. 

The direct primary care model allows doctors to cap their patient panel at a manageable number, typically around 600. This is in contrast to the 2,000+ patients physicians who work in insurance-based practices often have to care for.

A smaller patient load reduces the risk of burnout and allows physicians to provide more comprehensive care. Additionally, DPC doctors typically report higher job satisfaction than their counterparts working under traditional healthcare models because they feel more connected to their patients and in control of their care provision. 

4. Improved financial stability for physicians

The direct primary care financial model explained in simple terms is this: recurring revenue through monthly membership. This stability makes it easier for doctors to manage their finances and invest in their practices. There's no longer a need to waste time guessing when insurance reimbursements will arrive or what percentage will be denied. 

Doctors also get to set their rates under the DPC model, allowing them to set the price of their expertise. This freedom allows them to offer specialized services, like spinal leak care, that often aren't adequately reimbursed in traditional settings. For example, epidural blood patches are the gold standard for CSF leak care, but hospital insurance reimbursement rates can be as low as $75. 

5. Improved preventative care 

Patients who don't have to worry about co-pays or hidden fees are more likely to visit the doctor for minor issues before they become major health problems. This leads to a greater focus on preventative care, equally beneficial to patients and physicians. 

DPC allows doctors to take a proactive approach, working with patients to manage chronic conditions, identify risk factors, and improve their overall quality of life. 

For example, rather than rushing through a seven-minute visit, DPC physicians can spend time discussing lifestyle choices, such as diet, exercise, and stress management routines, that could exacerbate patients' health issues. This holistic approach to healthcare leads to reduced hospitalizations, lower healthcare costs, and better health outcomes.

6. Builds more trust with patients

Another benefit of direct primary care is its transparency. Patients know exactly how much they'll pay monthly without worrying about hidden fees. This transparency builds trust, especially with patients who've had negative experiences with traditional healthcare providers. It also allows the market to better set the price through direct competition between transparent DPC clinics, allowing patients to decide where to receive care.

DPC also allows physicians to provide personalized care, which helps build trust. Patients appreciate little things like a doctor remembering their name before picking up their file, understanding their health history, and treating them as individuals rather than case numbers. 

It's impossible to overstate how much patients overlooked in the traditional healthcare system appreciate the ability to establish genuine relationships with their doctors. 

7. Simplified operations for providers

Running a traditional medical practice involves navigating mountains of paperwork and complicated billing systems. DPC simplifies this since insurance providers are no longer the primary source of earnings. This allows providers to operate more efficiently with less staff and lower overhead costs. 

The simplified model allows physicians to offer creative solutions like mobile phlebotomy services or virtual appointments. These innovations make managing practices, increasing profits, and improving patient experience easier. 

8. A healthier focus on care

The shared goal at the heart of the direct primary care model is improving healthcare outcomes. Patients receive the care they need when needed, while doctors focus on providing quality care instead of treating as many patients as possible. This shift in priorities benefits physicians and their patients equally, fostering a healthier, more efficient healthcare environment. 

Given its many pros, it's easy to understand why direct primary care has gained popularity in recent years. However, being a popular model doesn’t necessarily mean physicians are successful in direct primary care. The model must be used correctly to demonstrate value, which can be a missed step for medical doctors. We will cover some gaps next. 

The Cons: Potential Downsides of Direct Primary Care

Despite its numerous benefits, DPC isn't a perfect model. Every healthcare model has limitations, and direct primary care is no exception. 

Let's explore some common challenges of DPC to help you determine if it aligns with your goals: 

1. Limited coverage for specialist care and hospitalization

One of the most valid criticisms of direct primary care is that the membership fee may be paired with insurance to cover emergency visits, major surgeries, or hospital stays, and this total can create overwhelming costs for the patients. While the flat monthly fee covers most primary care services, it doesn't eliminate the need for health insurance to cover everything else. 

Patients who opt for DPC often pair it with high-deductible health plans (HDHPs) to cover major medical issues, adding a new cost layer. 

2. Inaccessible for low-income patients

While direct primary care is more affordable than traditional options, the monthly subscription fee can burden low-income patients. For people struggling to make ends meet, paying a monthly subscription fee of around $100 to $500 is often not an option. 

Patients who prefer DPC must also pay insurance premiums to cover major medical needs. The double expense might not be worth it for patients with minimal healthcare needs. 

However, there still might be an education option here where physicians can explain the cost-effectiveness of paying for direct primary care with arguments for accessibility, such as considering public transportation costs and time off work and factoring these into patients’ totals when visiting primary care centers in person rather than an accessible virtual clinic as one model. 

3. Major geographic impact on accessibility

Direct primary care is most common in urban and suburban areas with higher population densities, leaving people in rural areas with fewer options. 

The challenge in launching clinics using the DPC model in rural areas is building a large enough patient base to sustain the practice. Patients in rural areas may also have limited access to nearby specialists and diagnostic facilities, further complicating the model's ineffectiveness. 

Some direct primary care businesses operate at high costs unnecessarily in rural areas and pass this on to patients. One patient with a spinal CSF leak reported paying $20,000 per year for a direct primary care physician. What often happens in these situations is a lack of delegation as the physicians themselves make house visits, take blood, and perform other procedures. 

These tasks could easily be outsourced to more experienced individuals, such as mobile phlebotomists, and the physician could then review the lab work remotely. One of our clients offered accessible and affordable services to rural Georgia by operating virtually from Atlanta and taking urban, suburban, and rural patients. Due to this client's demonstrated focus on accessibility, we also won multiple small business grants for them. 

4. The double-edged sword of small patient panels

One of the major selling points of direct primary care is the smaller patient panel, which allows for personalized care. However, this setup can also create challenges, as smaller panels mean practices can fill up quickly, leaving some patients without access. 

Maintaining a limited patient panel requires careful financial planning for providers. While the predictability of their monthly incomes from subscriptions offers stability, practices that don't have enough patients might struggle to cover overhead costs. 

Balancing affordability for patients and profitability for the practice can be tricky for DPC clinics, particularly newer practices. 

5. Dependence on provider availability

Direct primary care emphasizes improved accessibility, like same-day appointments or 24/7 texting, which can be a blessing and a curse. Patients may start to expect immediate responses to their concerns, which can lead physicians who don't establish clear boundaries to burnout. Having a dedicated support team ready to field responses and setting reasonable timeframes to respond with an emergency line for after-hours can be helpful in such situations. 

Most patients simply want someone to respond, as they are often ignored for weeks or months via portals, and 24/7 access can be an oversell. Some physicians might respond at midnight to a patient's email after work about a non-urgent issue that the patient did not need to be answered immediately.  

The heavy reliance on constant access to physicians can also create complications if a DPC doctor is unavailable due to illness, family emergency, or vacation. DPC clinics are often operated by a single physician, leaving patients without backup options. 

While there is some pushback against the use of advanced practice providers (APP) in the form of physician assistants (PAs) or nurse practitioners (NPs), with oversight from the medical doctor and mandatory continuing education for all clinical staff, DPC physicians can create a cost-effective team to offer quality and continuity within team-based care.   

6. Not ideal for patients with minimal healthcare needs

The monthly subscription fee for direct primary care may be unnecessary for generally healthy individuals. The membership cost could outweigh the benefits if you only see a doctor once or twice yearly. Such patients might prefer a fee-for-service or traditional insurance model for occasional visits. 

7. Launching a direct primary care practice can be challenging for physicians

Transitioning from working in hospitals to launching a cash-based clinic can be daunting. Leaving the traditional hospital system means giving up a stable salary, navigating legal and logistical hurdles, and building your patient base from scratch. 

The financial risk is significant, particularly during the early stages of launching a DPC practice. 

Providers must also educate potential patients on how the direct primary care model works. Many people are unfamiliar with the model, making them hesitant to sign up. Overcoming this hurdle requires consistent effort, marketing savvy, and time. 

As always, building trust is crucial before potential consumers make a purchase. Far too many providers mistakenly believe that their credentials alone are a tantalizing carrot that will encourage many patients to sign up for this new model. 

However, this does not match reality, and a physician who understands the need to invest in initial trust-building before converting leads to patients gains a competitive edge. 

8. Regulatory uncertainty

Direct care operates in a legal grey area in some states. Some regulators have tried to categorize DPC as insurance, even though it isn't, placing additional legal requirements on providers. 

Many offices are overly cautious about approaching patients with Medicaid or Medicare because they are unsure if they will be penalized for charging cash. However, there is no need to fear, as more attorneys offer specialized support services for cash-based practices. 

Practices need to invest in retaining an attorney to advise on these matters–not only to be armed with the information they need to answer interested consumers confidently but also for peace of mind rather than resorting to guesswork.

While most states have specific legislation that supports DPC, the potential for regulatory changes in the future creates an element of uncertainty. 

9. Potential use of services beyond estimations

Sometimes, the estimated use of services does not match the actual amount that patients might participate in care. Some patients might use more than the estimated average access by frequently scheduling appointments or contacting their physician multiple times daily. 

This overutilization can strain resources and disrupt the balance between efficiency and personalized care. It is crucial here to validate patient concerns instead of getting frustrated. 

Far too often, providers react negatively to behaviors like these instead of attempting to discover the root cause of this behavior, such as fear that a terrifying issue is not being appropriately addressed. 

Such fears often lead to patients attempting to solve their issues independently and constantly bringing suggestions to the physician. In many cases, patients might be willing to pay more for a higher level of care; however, they will likely feel invalidated if they are told that they are too much to deal with, which is dehumanizing. 

Instead, respect is key, and the physicians can ensure they clarify what is offered in each membership service package, such as the number of visits per month. They can also offer the option to add even more single-purchase visits.   

10. Patient expectations vs. reality

Patient expectations don't always align with the realities of DPC. Some assume the monthly fee covers all their healthcare needs, only to be surprised they have to pay for additional services like advanced imaging. 

There is a critical need for education, including the fact that DPC physicians can send in orders with notes for imaging to centers such as a local in-network hospital system. The latter is responsible for securing insurance coverage but will need detailed notes from the DPC physician to make a case. 

Additionally, patients can be educated on average co-pays with their insurance for in-network services ordered by their DPC physician versus what other cash-based options exist and which are more affordable. 

For example, third-party imaging services may sometimes charge $400 for a brain MRI but use a 1.5T MRI machine, while a hospital may charge a $500 co-pay for a brain MRI but use a much higher-quality 3T MRI machine. Clear communication is crucial to setting realistic expectations and avoiding misunderstandings. 

Weighing the pros and cons of direct primary care

Direct care isn't a one-size-fits-all solution but offers a refreshing alternative to traditional healthcare. Understanding the pros and cons of direct primary care helps you decide if this is the right model for you—whether you're a patient seeking more personalized care or a provider exploring potential business models for private practice. 

Key considerations for patients

Start by evaluating your current healthcare needs and finances. DPC generally works best for individuals or families who:

• Need frequent access to a primary care physician: Direct primary care can provide unmatched convenience to patients with health issues like spinal leaks who need to visit a physician regularly to manage their condition. 
• Manage chronic conditions: Patients with chronic health conditions such as diabetes, hypertension, or heart disease benefit from DPC's continuity of care and personalized approach. 
• Desire transparency and predictability: The flat monthly fee eliminates surprise medical bills, making budgeting for your healthcare needs more straightforward. 

However, direct primary care might not be ideal if:

• You rarely visit a physician and have minimal healthcare needs. 
• You rely heavily on health insurance for specialist visits, hospitalizations, and prescriptions not covered under the DPC model. 
• You're not comfortable maintaining health insurance in addition to your DPC membership. 

Key considerations for physicians

Transitioning to a direct primary care model is a considerable leap for physicians, and they must carefully evaluate its pros and cons. However, it can be a game-changer for physicians who desire more autonomy, improved work-life balance, and a deeper connection with their patients. 

Some of the things you should ask yourself to determine if DPC is right for you include: 

Are you financially prepared? Transitioning to DPC often requires leaving a stable salary behind and building your patient base from scratch. This means you should have enough of a financial safety net to sustain your practice during the first several months as you grow your patient base. 

Do you have an entrepreneurial mindset? Running a DPC practice requires more than clinical skills. You must also manage marketing, patient education, and administrative duties. 

Are you passionate about patient care? The DPC model thrives on close relations between patients and physicians. Direct primary care could be a fulfilling career path if you enjoy spending more time with patients. 

Making the transition to DPC

Patients and providers should carefully evaluate the pros and cons of direct primary care before deciding. Some of the steps to take include: 

Talk to current DPC members or providers: Hearing firsthand experiences can provide valuable insights on what to expect. 

Evaluate the financial implications: Crunching the numbers is crucial for patients calculating monthly costs or physicians planning to transition to the direct primary care model. 

Research local options: Physicians should assess their local markets to determine the demand for DPC, while patients should explore the availability of clinics. 

Weight the pros and cons: Reflect on the benefits and drawbacks of direct primary care outlined in this guide. Understanding both sides of the equation will help you make an educated decision on what suits you best. 

A personal approach to modern healthcare

Direct primary care offers patients a refreshing alternative to traditional healthcare, emphasizing accessibility, transparency, and personalized care. It is affordable for patients who need regular access to a physician and offers physicians a pathway to reclaim their autonomy and rediscover the joy of providing care. 

Direct primary care has its share of limitations for patients and providers, so it's vital you understand your unique needs, research your options, and weigh the pros and cons thoughtfully. 

Ultimately, DPC isn't just a healthcare model; it's a commitment to a more personal, patient-centered approach to medicine. From patients to physicians, direct primary care has the potential to transform how you experience healthcare—one meaningful interaction at a time.