Direct Primary Care for Clinics: How the Membership Model Works, What It Costs, and What Your Practice Needs to Run One

Direct primary care is a simple idea with a big operational change behind it. Patients pay your practice a flat monthly fee, and in return they get a defined set of primary care services without an insurance claim for each visit. No copay at the door, no claim filed for a routine visit, no prior authorisation for the care the membership already covers.

This guide explains the model the way a clinic owner needs it: what patients pay, what the practice earns, the 2026 tax change on health savings accounts, the rules that catch new practices out, and the setup a membership practice needs. The figures come from the American Academy of Family Physicians and the IRS, and they are attributed where they appear. The examples are illustrative. Nothing here is legal or tax advice, so check your own position with counsel before you change how you charge.

What Direct Primary Care Actually Is

The American Academy of Family Physicians defines direct primary care as a practice and payment model in which patients pay their physician or practice directly, in the form of a periodic fee, for a defined set of primary care services. The practice does not submit claims to insurers for the services the membership covers. That is the whole model in one sentence, and every decision that follows comes back to it.

A membership usually covers longer visits, same-day or next-day appointments for acute problems, direct messaging with the doctor, phone calls, care coordination, and routine follow-up. It does not cover hospital care, surgery, emergency care, or specialist visits, so patients still need insurance for everything outside primary care. A practice that explains that boundary at sign-up avoids the most common complaint later, a patient discovering the membership does not pay for a hospital stay.

The model is small but growing. The AAFP reports that almost 10% of its members surveyed were in a direct primary care practice as of 2023, up from 5% in 2021, and that the average DPC panel sits at 402 patients. Commonly cited figures put a traditional panel at roughly 1,500 to 2,500 patients per physician, so a DPC doctor carries a much smaller list. That smaller panel is the point of the model, and it is also the risk, because the practice earns its income from those few hundred memberships.

How a Membership Practice Works Day to Day

A day in a DPC practice is built around access rather than volume. Visits run 30 to 60 minutes instead of 10 to 15, same-day slots are held open for acute problems, and much of the work happens by message or phone. A problem that can be solved in a five-minute call never becomes a visit at all.

• Visits without a per-visit charge: routine, sick, and follow-up visits, in person or by video, for as long as the membership is active.
• Direct access: patients message or call the doctor directly instead of queuing through a front desk, and the practice answers the same day.
• Longer appointments: 30 to 60 minutes for a routine visit, so the doctor can deal with two or three problems instead of one.
• Care coordination: referrals, results, and follow-up tracked by the practice, not left to the patient to chase.
• Transparent extras: labs, imaging, and procedures outside the membership are priced in advance, so the patient knows the cost before agreeing.

The front desk changes too. There is no insurance verification for each visit, no claim to file, and no denial to appeal for the care the membership covers. The work moves to enrolment, renewals, and keeping members informed. That is a smaller admin load, but it is a different one, and a practice that keeps its old front-desk routines will feel the mismatch quickly. Our guide to missed calls in medical practices describes what happens when the phone is the weak point, and in a membership practice the phone matters more, because access is what members are paying for.

What Patients Pay, and What the Practice Earns

Fees vary by age, location, and what the membership includes, but the AAFP data brief gives a useful range. Individual adults typically pay $50 to $100 a month, children $20 to $49, and families $100 or more. One electronic health record vendor's survey of about 200 DPC doctors put the average adult fee at $65 to $85 a month. Treat these as starting points, not a price list, because a practice in a high-cost city will charge more than a lean practice in a small town.

Do the maths before you set a fee. At $75 a month and 400 members, the practice takes in $30,000 a month before costs, and that has to cover rent, staff, the EHR, malpractice cover, and the doctor's own income. The model works when the panel is full and churn is low, and it struggles when the panel is half full, because the costs stay roughly the same while the income halves.

Price the membership to the service, not to the market average. List exactly what the fee covers, and price the extras separately and in advance. A fee that looks cheap but excludes the services patients use will cost you members, and a fee set too low will cost you the practice.

If you are weighing the cost of the technology behind a membership practice, our guide to how much a patient portal costs sets out the implementation routes and their price bands, so you can budget the portal before you promise it to members.

Direct Primary Care vs Concierge Medicine

Patients confuse the two, and some practices use the names as if they were the same. They are not, and the difference matters for pricing, for the HSA rules, and for what you promise.

The practical difference is the fee and the billing. A concierge practice charges a retainer for enhanced access and still bills insurance for visits, while a DPC practice charges a membership fee instead of billing insurance for the care it covers. The IRS treats the two differently too: from 2026, qualifying DPC fees can be paid from an HSA, while a concierge retainer that only buys preferred access generally cannot.

Do not sell DPC as concierge medicine. Patients who expect a concierge service at a DPC price will be disappointed, and patients who want DPC will be put off by a concierge price. Name the model plainly on your website, and put the fee and what it covers on the same page. Our guide to healthcare website development cost covers what a clear pricing page takes to build.

The 2026 HSA Change, in Plain English

Until 2026, the tax rules worked against direct primary care. The IRS treated a DPC membership as a health plan, so a patient with one generally could not contribute to a health savings account. That changed on January 1, 2026, when the One Big Beautiful Bill Act, signed on July 4, 2025, created a new category called a direct primary care service arrangement, explained by the IRS in Notice 2026-5.

The change has two parts. First, a patient enrolled in a qualifying DPC arrangement can keep contributing to an HSA. Second, the patient can pay the monthly DPC fee from the HSA, tax-free. Both parts only apply if the arrangement meets the definition and the fee stays within the caps: $150 a month for an individual arrangement, $300 a month for an arrangement covering more than one person. The caps are indexed for inflation after 2026, and the IRS has confirmed they stay at $150 and $300 for 2027.

Three conditions decide whether an arrangement qualifies. It must provide only primary care services, delivered by primary care practitioners, for a fixed periodic fee that stays within the caps. It must not cover procedures needing general anaesthesia, prescription drugs other than vaccines, or lab services not typically done in an ambulatory primary care setting. A fee above the cap does not stop the patient paying it from an existing HSA, but it does stop new HSA contributions while they are enrolled. Read the IRS announcement in full in the IRS newsroom notice on the new HSA rules.

The HSA change does not remove the need for a high-deductible health plan. To contribute to an HSA in 2026, a patient still needs a qualifying plan, with a minimum deductible of $1,700 for self-only cover or $3,400 for family cover. The DPC membership covers primary care. The health plan covers the hospital stay, the surgery, and the specialist. Tell patients that plainly, in writing, before they join. A member who believes the membership replaces insurance will blame the practice when the hospital bill arrives.

For a practice, the HSA change is a marketing fact and a pricing constraint at the same time. Fees at or below the caps are easier to sell to patients with HSAs. Fees above the caps are still legal, but they cost the patient their HSA contributions, so think carefully before raising a fee past the line.

Insurance, Medicare, and the Rules You Cannot Skip

A direct primary care agreement is not insurance, and that sentence needs to appear in the agreement itself. Most states that have legislated on DPC require the agreement to state prominently, in writing, that it is not health insurance. Thirty-four states have passed laws or regulations defining DPC as a medical service outside insurance regulation. The rules differ by state, so check your own state's position before you draft anything.

Medicare needs care. A DPC practice cannot bill Medicare for the services the membership covers, and a Medicare patient who joins still pays the fee out of pocket. Some DPC doctors opt out of Medicare entirely. Either way, the position must be clear before the patient signs, so take legal advice on the Medicare question specifically.

HIPAA still applies in full. A membership practice holds the same patient information as any other practice. Patient messages, portal records, and payment details all need the usual protections, and any vendor that handles patient data on your behalf needs a business associate agreement. HHS publishes sample business associate agreement provisions that show what one should cover. The AAFP answers the common questions about the model in its direct primary care FAQs.

Which Clinics the Model Fits, and Which It Does Not

DPC fits a primary care practice with a loyal patient base, a clinician who wants longer visits, and a local market where patients can afford a monthly fee on top of insurance. It fits family medicine, internal medicine, and paediatrics, and a doctor who would rather have 400 patients they know well than 2,000 they barely see.

It does not fit every clinic. A practice that depends on walk-in volume, a clinic in an area where most patients are on Medicaid, or a specialty practice will struggle, because the model is built for primary care and for patients who can pay a monthly fee. A practice with high fixed costs and a thin margin has little room for the slow panel build. And a clinician who does not want to be messaged directly should not promise direct access.

A hybrid is possible, and many practices run one: a traditional panel alongside a DPC panel, or a gradual conversion as the membership list grows. Keep two sets of rules cleanly apart, which patients are members, what each group is charged, and what each group can expect, because mixed billing is where the mistakes happen.

What Your Practice Needs to Run One

The setup is where a DPC launch succeeds or fails, and it has five pieces.

• A membership agreement, in plain language: what the fee covers, what it does not, how to cancel, what happens to records, and the statement that it is not insurance. Have a lawyer review it.
• A way to take payment every month: card billing that runs itself, with failed payments chased kindly and quickly, because a missed payment is a lapsed member.
• A [patient portal](/solutions/ai-patient-portal) and a messaging route: booking, results, prescriptions, and direct messages in one place, so the doctor is reachable without the phone ringing all day.
• A phone service that holds up: members will call, and they expect an answer. An AI medical receptionist can take the routine calls, book visits, and pass the urgent ones to a person.
• A website that sells the membership honestly: the fee, what it covers, who the doctor is, and how to join, on one page, with no jargon.

Panel size decides the maths. The AAFP average is 402 patients, and a practice should plan its costs around the panel it can realistically hold, not the panel it hopes for. Work out the monthly cost of running the practice, divide by the fee, and you have the number of members you need to break even, with a margin for churn.

Keep the admin light. The model promises less paperwork, and members notice quickly if the practice recreates the bureaucracy it promised to escape. One system for the record, one for messages, one for payment, and a weekly check that nothing is slipping.

Your intake flow matters more in a membership practice than in a traditional one, because the first visit sets the tone for the whole relationship. Collect the history, the medicines, and the goals before the visit, so the first appointment is a conversation, not a form-filling exercise.

Mistakes That Sink New DPC Practices

• Pricing from the average, not from your costs. A fee copied from another city ignores your rent, your staff, and your panel size.
• Promising unlimited everything. Same-day access, home visits, and direct messaging are real promises. If you cannot keep them at 400 members, do not offer them at 40.
• Hiding the fee. Patients who cannot find the price will assume it is high. Put the fee on the website, with what it covers beside it.
• Letting members drift. A member who has not been seen or messaged in six months is a cancellation waiting to happen. Check in, even briefly.
• Mixing the panels. A hybrid practice that bills a member like a fee-for-service patient, or treats a traditional patient like a member, will create billing errors and bad feeling.

The common thread is overpromising. Promise what you can keep on a busy week, and keep it.

The Bottom Line

Direct primary care trades volume for relationship. Patients pay a flat monthly fee, see the same doctor for longer, and reach them directly, while the practice takes on the work of keeping a few hundred members happy. The 2026 HSA change makes the model easier to sell, but it does not make it easy to run. If you want help shaping the systems behind a membership practice, see the demos or request a quote.