Direct Primary Care Works Everywhere. Here Is Why.

A plain-language explainer for every physician and physician-in-training, now updated with the landmark HSA changes from the One Big Beautiful Bill Act (H.R. 1), signed into law July 4, 2025.

12 minute readUpdated February 2026 HSA Update Included

In this guide

1. What Direct Primary Care actually is

2. The incentive problem, and why it matters

3. What changes in daily practice life

4. The business model, plainly explained

5. The HSA breakthrough: H.R. 1 and what it means 2026 UPDATES!

6. DPC works everywhere, not just where you think

7. The equity question, answered honestly

8. Common concerns, addressed

9. Is DPC right for you?

10. Where to go from here

Section 01

What Direct Primary Care Actually Is

Strip away the policy language, the acronyms, and the healthcare industry jargon, and Direct Primary Care comes down to one idea: your doctor, paid directly by you, every month, without an insurance company in the middle of every routine interaction.

In a DPC practice, patients pay a flat monthly membership fee, typically somewhere between $50 and $150 depending on age, region, and services included. In exchange, they receive comprehensive primary care from a physician who keeps a small panel, picks up the phone, and has time to actually think.

There are no per-visit co-pays. No billing codes to justify. No prior authorizations for primary care. No reimbursement negotiations with payers. The physician earns revenue from members. The patient gets access to their doctor.

DPC is often confused with concierge medicine. They are related but distinct. Concierge practices typically charge a membership fee on top of continued insurance billing, making care more expensive. DPC replaces insurance billing for routine care entirely, keeping the membership fee as the sole payment mechanism for primary care services. Patients still carry insurance for hospitalizations, specialist care, imaging, and emergencies. They use their membership for everything their primary care physician can handle.

DPC is not anti-insurance. It is pro-clarity. Insurance handles what it was designed for: catastrophic and specialized care. Your primary care physician handles the rest, without the administrative overhead of filing claims for every interaction.

Section 02

The Incentive Problem, and Why It Matters

To understand why DPC exists, you have to understand the structural problem it is trying to solve.

In traditional fee-for-service medicine, a physician's revenue is directly tied to visit volume. More visits, more revenue. Faster visits, more visits per day. The system, entirely independent of anyone's intentions, creates a financial incentive that points toward speed.

Over time, that incentive produces predictable cultural outcomes:

• Appointment slots compress to 10 or 15 minutes because longer appointments require fewer patients per day and less revenue

• Panel sizes grow to 2,000 or more because a larger panel means more potential visits

• Administrative staff expand to manage billing, coding, and insurance appeals

• Physicians begin charting after hours because there is no time during the day

• Preventive conversations get squeezed or skipped because they cannot be billed at a level that justifies the time

None of this is the result of bad physicians. It is the result of a structure that rewards a specific kind of behavior, and that over years, shapes the culture of an entire profession.

I didn't leave medicine. I left a payment model that was slowly making medicine impossible to practice.

DPC Physician, My DPC Story Podcast

DPC restructures the incentive. Revenue is tied to membership size, not visit count. Once a panel is stable, the physician earns roughly the same whether they see a member three times in a month or zero times. That shift, subtle on paper, is transformative in practice.

When revenue does not depend on volume, the incentive points toward keeping patients healthy rather than keeping them coming back. Preventive care becomes financially rational. Extended appointments are no longer punished. Phone calls replace unnecessary visits. The physician spends time thinking rather than performing.

Section 03

What Changes in Daily Practice Life

The numbers are one thing. The texture of daily practice is another. DPC physicians describe a qualitative shift that the statistics alone do not fully capture.

Time becomes clinically available

Medicine requires cognitive bandwidth. To diagnose well, to really listen, to detect the inconsistency buried in a patient's narrative or the fear behind the presenting complaint, you need time. Not unlimited time. Sufficient time. The 15-minute visit model does not primarily reflect how quickly medicine can be practiced. It reflects how quickly medicine must be practiced to generate sufficient billing revenue.

In DPC, extended visits are the norm rather than the exception. Physicians describe being able to:

• Hear the full story without watching the clock

• Hold multiple diagnostic possibilities in mind rather than defaulting to the most efficient answer

• Address lifestyle, behavioral, and social factors that rarely fit in a rushed appointment

• Think between patients rather than sprint between rooms

Access becomes direct and immediate

With smaller panels, DPC physicians can offer what high-volume practices structurally cannot: genuine same-day or next-day access, direct physician messaging, and the ability to field a call before it becomes an ER visit. Patients know their physician's name. The physician knows their patient's history. That continuity is not a luxury. It is a clinical advantage.

Administrative burden drops significantly

A substantial portion of the administrative load in traditional primary care exists entirely to manage insurance billing. Coding, claims submission, prior authorizations, appeals, denial management. DPC eliminates most of this infrastructure. Physicians describe spending time on clinical work rather than documentation designed primarily to justify reimbursement.

One DPC physician put it simply: "I used to spend two hours a day documenting for insurance. Now I spend that time with patients or thinking about their care. The math isn't complicated."

Section 04

The Business Model, Plainly Explained

A persistent myth about DPC is that it is financially fragile or inaccessible. That myth persists largely because physicians are trained in medicine, not business, and unfamiliarity reads as impossibility. The numbers tell a more straightforward story.

Why overhead is the key variable

In traditional primary care, a significant share of revenue covers the cost of billing. Coding staff, claims processors, denial management, compliance infrastructure. This overhead is so embedded that most physicians never see it clearly. It simply manifests as the volume requirement: the number of patients you must see each day to keep the practice solvent.

DPC eliminates most of that billing overhead. Without insurance claims to file and defend, the practice does not need a billing department. That overhead reduction allows a smaller patient panel to sustain a financially viable practice.

The math, briefly

Consider a physician with 550 members at an average of $85 per month. That is roughly $46,750 in monthly gross revenue, or $561,000 annually. After a modest staff, rent, malpractice insurance, an EMR subscription, and taxes, many DPC physicians arrive at a take-home income that is competitive with employed primary care positions, while seeing 8 to 12 patients per day rather than 25 to 30.

Startup costs vary widely, but many DPC practices launch for under $50,000, and some considerably less. Because the model does not require large staff, elaborate billing infrastructure, or high patient volume from day one, the barrier to entry is meaningfully lower than traditional private practice. Panel growth is gradual, typically reaching stability over 12 to 24 months.

The comparison table below illustrates the structural contrast:

Section 05 — 2026 Update

The HSA Breakthrough: What H.R. 1 Changed for DPC

For years, one of the most frustrating structural barriers to DPC adoption was a peculiar IRS classification. The agency treated DPC membership arrangements as a form of "other health coverage," which meant that enrolling in a DPC practice could disqualify a patient from contributing to a Health Savings Account (HSA). Patients had to choose between tax-advantaged savings and direct primary care access.

That barrier is now gone.

Legislative Update — Effective January 1, 2026

The One Big Beautiful Bill Act (H.R. 1)

Signed into law on July 4, 2025, H.R. 1's Section 71307 makes two landmark changes to federal tax law that directly benefit DPC patients and practices.

Summary:

Change 1: DPC arrangements are no longer treated as health plans for HSA eligibility purposes. Participating in DPC no longer disqualifies patients from contributing to an HSA.

Change 2: HSA funds can now be used tax-free to pay DPC membership fees, provided the arrangement meets federal requirements.

Health Savings Account expansion for participants (Section 71307)

Overview of changes and benefits

Telehealth and remote care services

• Telehealth and other remote care services can now be received before meeting a high-deductible health plan deductible

• People can still contribute to their Health Savings Account (HSA) even after using telehealth before meeting the deductible

• This rule is permanent for plan years starting on or after Jan.1, 2025.

Expanded eligibility for bronze and catastrophic plans

• Starting Jan.1, 2026, bronze and catastrophic health insurance plans are treated as HSA-compatible

• This applies whether the plans are bought through an insurance exchange or not

• This change makes more people eligible to contribute to an HSA, including individuals who previously could not because their plan did not meet the strict HDHP definition

Direct primary care arrangements

• Beginning Jan.1, 2026, people enrolled in certain direct primary care (DPC) service arrangements may:

  • Contribute to an HSA if they otherwise qualify

  • Use HSA funds tax-free to pay periodic DPC fees

Call for comments

• Treasury and the IRS invite public comments on the guidance by March 6, 2026, via the federal rule making portal or by mail

Individual Monthly Cap (For those looking to fund an HSA)

$150

HSA-reimbursable per month for individual memberships

Family Monthly Cap (For those looking to fund an HSA)

$300

HSA-reimbursable per month for family arrangements

2026 IRS Guidance UPDATE HERE:

https://www.irs.gov/newsroom/treasury-irs-provide-guidance-on-new-tax-benefits-for-health-savings-account-participants-under-the-one-big-beautiful-bill05

Confirms

DPC es qualify as reimbursable medical expenses

What this means in practice

The practical impact is significant. A patient on a qualifying high-deductible health plan can now fund their HSA, use those pre-tax dollars to pay their DPC membership fee, and cover their primary care costs with money that was never taxed. For a family paying $250 per month for DPC membership, the annual tax savings in a 25% bracket could approach $750 or more annually, simply by routing the payment through an HSA.

For physicians operating or considering a DPC practice, this change removes one of the most common objections they heard from prospective patients. The conversation about affordability just changed.

For patients who were previously told they had to choose between their HSA and DPC, the answer is now simple: starting January 1, 2026, you no longer have to choose.

What arrangements qualify

Not every practice calling itself DPC automatically qualifies for HSA treatment under the new law. The arrangement must meet specific federal criteria:

• Services must consist solely of primary care services provided by primary care practitioners

• The practice cannot provide procedures requiring general anesthesia, prescription drugs other than vaccines, or laboratory services not typical of an ambulatory primary care setting

• Compensation must be a fixed periodic fee with no additional per-visit charges

• Total fees across all DPC arrangements for an individual cannot exceed the monthly caps

Physicians building or restructuring DPC practices should confirm their arrangement meets these criteria, and work with a healthcare attorney familiar with the IRS guidance to ensure compliance.

Section 06

DPC Works Everywhere, Not Just Where You Think

One of the most persistent misconceptions about Direct Primary Care is that it is a niche model for affluent urban neighborhoods, a coastal experiment with limited relevance to the rest of American medicine. The reality is more interesting, and more hopeful, than that.

DPC has taken root across wildly different communities precisely because the structural problem it solves is not geographic. The misalignment between payment incentives and clinical values exists in rural farmland, mid-size suburbs, dense urban cores, and everything in between. The solution travels with the structure.

Rural Communities

Often the only primary care option for miles. Lower overhead allows viability with smaller panels. Deep continuity with a community that desperately needs it.

Urban Centers

High patient density supports membership growth. Employed professionals value same-day access. Employer-sponsored DPC contracts are increasingly common.

Suburban Markets

Family-centered care with strong word-of-mouth. Families with children benefit from the unlimited visit model. Pediatric DPC hybrids are growing here.

Employer-Sponsored

Small and mid-size businesses offering DPC as a benefit to employees. Reduces downstream healthcare costs while offering workers direct care access.

The rural argument deserves its own attention

Rural medicine faces a specific crisis: not enough physicians, too many patients, and systemic underreimbursement for the communities that need care most. The traditional private practice model is often economically unviable in low-density areas. High overhead, small billing volume, and limited specialist backup make it difficult to sustain.

DPC flips several of those variables. Lower administrative overhead means a viable practice does not require the same billing volume. A physician with 400 members in a rural county can run a financially stable practice that would be impossible under fee-for-service economics. And because DPC panels are smaller, the physician actually knows their patients, building the kind of longitudinal trust that transforms health outcomes in communities where trust in the medical system has often been eroded.

DPC let me build something sustainable here, because I'm not trying to generate enough billing volume to survive.

Rural DPC Physician, My DPC Story Podcast

Urban DPC solves different problems

In dense urban markets, the challenge is different. Physicians exist, but access is fragmented. Patients with good insurance still wait weeks for appointments, see a different provider at each visit, and struggle to reach their physician directly. Urban DPC addresses the relationship and continuity deficit, not the scarcity deficit.

Urban DPC physicians are increasingly partnering with employers. A company with 50 to 200 employees can contract with a DPC physician as a benefit, giving workers same-day access to a physician who knows their health history. This model extends DPC to hourly and working-class employees who would not pay a membership fee individually but benefit enormously from the access.

The suburban inflection point

Suburban markets often represent the sweet spot for DPC's initial growth. Families with children value the unlimited visit model. Parents call rather than drive to urgent care. The monthly fee competes favorably against high deductibles and urgent care co-pays. Word-of-mouth spreads quickly in communities where parents talk at school events and neighbors know neighbors.

Suburban DPC physicians often build their initial panels through community relationships rather than traditional marketing, and they find that the model sells itself once a few families experience what extended access actually feels like.

Section 07

The Equity Question, Answered Honestly

If DPC reduces panel sizes, and if every primary care physician adopted it, would access collapse? This is a legitimate concern and deserves a direct response rather than a deflection.

The honest answer is nuanced. Access is not a single variable. High panel sizes create nominal access: there are technically enough appointment slots if patients can wait three weeks, see whoever is available that day, and settle for 12 minutes of attention. Whether that constitutes meaningful access is a different question.

DPC does not automatically solve the access problem. But neither does high-volume medicine automatically create meaningful care. The real equity challenge in DPC is pricing and intentional design.

Equity requires design, not assumption

The DPC model provides flexibility that traditional practice does not. Physicians who choose to build equitable practices have structural tools available to them:

• Tiered pricing structures based on income or age

• Family membership caps that make multi-person coverage affordable

• Scholarship or community-sponsored memberships for patients who cannot afford market rate

• Employer contracts that bring DPC to working-class employees as a benefit they do not pay for individually

• Community health worker partnerships and safety-net collaborations

Now, with HSA eligibility expanded under H.R. 1, the affordability argument improves further. A working adult on a high-deductible plan, previously unable to afford a $75 monthly DPC fee after tax, can now route that payment through an HSA and reduce the effective cost through tax savings.

The model provides flexibility. The physician provides the ethics. Equity in DPC is not automatic, but it is possible, and the structural tools to build it are available to any physician willing to use them.

Section 08

Common Concerns, Addressed

DPC draws genuine questions from physicians at every stage. Here are the ones that come up most consistently.

Can I open a DPC practice right out of residency?

Yes, and a growing number of physicians do exactly that. It requires upfront planning, some business literacy, and ideally mentorship from established DPC physicians, but the startup process is simpler than traditional private practice. Many residency graduates who choose DPC describe the early learning curve as steep but manageable. The My DPC Story podcast has a growing number of episodes specifically featuring physicians who opened their first practice directly after residency.

What about Medicare and Medicaid patients?

Physicians who participate in Medicare cannot charge Medicare beneficiaries a membership fee for services already covered by Medicare, which creates a structural tension with DPC. Many DPC physicians opt out of Medicare participation entirely, which is a permitted and reversible decision. Some practices serve Medicaid populations through state pilot programs or managed care contracts with DPC clinics. Federal interest in DPC as a Medicaid delivery model is growing, and this space is evolving rapidly.

How does a DPC practice handle labs, imaging, and referrals?

DPC covers primary care. Patients use their insurance for specialist visits, imaging, hospitalizations, and other services outside primary care scope. DPC physicians often develop relationships with labs and imaging centers that offer deeply discounted cash-pay rates for their members, adding substantial value to the membership. They also coordinate referrals with more care and thoroughness than high-volume practices typically allow, because they have the time and the relationship to do so.

How long does it take to build a viable panel?

Most DPC practices reach financial stability over 12 to 24 months. Many physicians start with a founding panel of 50 to 150 members and grow through word-of-mouth, employer contracts, and community relationships. Income is modest in the early months, and many physicians supplement with part-time urgent care or telehealth work during the ramp-up phase. Reaching a stable panel of 400 to 600 members typically takes one to two years, though growth rate varies significantly by market, physician reputation, and marketing approach.

Is DPC legal in every state?

DPC is legal in all 50 states, but state regulations vary regarding structure, disclosure requirements, and whether membership agreements might be considered insurance contracts under state law. The majority of states have enacted DPC-specific legislation clarifying that membership agreements are not insurance products. Working with a healthcare or small business attorney who knows your specific state's framework is strongly recommended before opening a practice.

What if I have significant student loan debt?

Debt is often cited as the primary reason physicians avoid ownership. It is a real consideration, but it is often overweighted. A DPC practice with a stable panel of 500 to 600 members can generate a physician income comparable to or exceeding employed primary care, with greater long-term autonomy and equity. The question is less "can I afford DPC?" and more "can I manage the income variability of a 12 to 18 month ramp-up period?" Planning, financial coaching, and supplemental income during the growth phase make this manageable for many physicians. The DPC Directory includes financial advisors and consultants who specialize in this exact transition.

Section 09

Is DPC Right for You?

That is ultimately a question of honest self-knowledge rather than ideology. DPC is not the only ethical model in medicine. It is not superior to every alternative. But it is a meaningful alternative, and you deserve to evaluate it clearly.

DPC may align with you if you:

• Find yourself consistently wishing you had more time with patients

• Feel that administrative burden has grown disproportionate to its clinical value

• Are drawn to longitudinal relationships more than procedural variety

• Want schedule autonomy that employed positions rarely provide

• Are interested in building something that reflects your values, rather than inheriting institutional culture

• Are willing to accept early income variability for long-term autonomy and equity

DPC may not be the right fit if you:

• Strongly prefer a guaranteed salary and benefits from day one without early-stage uncertainty

• Find the business and operational responsibilities of ownership more draining than appealing

• Thrive in large institutional environments with extensive support infrastructure

• Are drawn toward procedural specialties or hospital-based care beyond primary care scope

Neither answer reflects a moral stance. They reflect honest self-knowledge about how you work best and what you need to sustain a career over 30 years. The most important thing is that you make this choice with full information, not by default.

Section 10

Where to Go from Here

Understanding DPC structurally is the first step. The second step is hearing from physicians who have actually built it, in their own communities, with their own constraints and fears and surprises. That is what My DPC Story exists to provide.

And when you are ready to find practices, tools, resources, and consultants specific to your region and situation, the DPC Directory is the place to start. Think of it as a curated search engine for everything DPC, built by and for people inside the model.

Starting points we recommend

On the My DPC Story podcast, look for episodes featuring:

• Physicians who opened their first practice directly out of residency

• Rural DPC founders serving communities with limited access

• Employer-sponsored DPC models reaching working-class patients

• Physicians from underrepresented backgrounds building ownership

• Mid-career physicians who restructured after burnout

• Discussions on the HSA changes and what they mean for patient outreach

On the DPC Directory, search for:

• DPC practices in your region or the region where you plan to practice

• EMR platforms designed specifically for DPC workflows

• Business consultants and coaches who specialize in DPC startup

• Healthcare attorneys familiar with your state's DPC regulations

• Financial advisors who work with DPC physicians navigating student loan strategy

My DPC Story

Updated February 2026 — HSA guidance reflects IRS Notice 2026-05 and H.R. 1 provisions effective January 1, 2026