The DPC question

Why CMT's NP and PA series treats direct primary care as a separate subject, what the evidence says about DPC's two main paths, and why "separate" does not mean "excluded."

An independent publication that drops a legitimate model from its coverage stops being independent. A publication that blurs different models together stops being accurate.

Briefs No. 18 through 20 examine nurse practitioners and physician assistants in concierge and membership-based medicine. A natural question is why direct primary care is treated separately. This brief answers that question by testing four common assumptions about DPC against the available evidence.

Concierge Medicine Today Editorial Research Desk. Michael Tetreault, Editor-in-Chief. Sources verified September 25, 2026.

Abstract

Summary

Question. Should CMT's NP and PA series include direct primary care in its recommendations, and is DPC structurally suited to NPs and PAs?

Approach. Four common assumptions about DPC were tested against association policies, practice surveys, industry transactions and peer-reviewed literature.

Findings. DPC largely operates on two paths, employer-facing and independent. Contrary to a common assumption, the employer path is operationally well suited to NPs and PAs. The independent path's physician-only professional community and staff-light micro-practice structure make it a poor fit for this series. Claims that independent DPC "struggles" financially are not established by the evidence.

Position. DPC is outside the scope of this series' recommendations, as noted in each brief's methodology. CMT continues to cover DPC as its own subject.

Results

Four common assumptions, tested

Common assumption	Evidence	Verdict
DPC splits into an employer path and an independent cash path	The DPC Coalition describes DPC offered directly to patients, through employers and unions, and alongside Medicare Advantage.¹ Large employer-facing DPC firms have consolidated into "advanced primary care" companies; Everside Health merged into Marathon Health, with more than 680 centers.²	Largely supported. Add a third path: hybrid and corporate-affiliated membership practices, the fastest-growing segment.³
NPs and PAs would not work well in the employer path	Employer onsite clinics are among the most APC-reliant settings. A 2019 large-employer survey found PAs at 63% of onsite clinics and NPs at 34%.⁴	Not supported. The employer path suits NPs and PAs well. The better reason to set it aside is that it has become corporate employment rather than physician-led relationship medicine.
The independent cash path struggles with sustainability	A 2017 survey of AAFP members found many family physicians perceived DPC financial sustainability as not assured.⁵ The DPC Alliance's 2024 survey found an average fee of $98.46 per month and more than 30% of practices operating with no staff.⁶ No rigorous national closure-rate data was located.	Unproven. Evidence is insufficient either way. Rising prices suggest adaptation rather than collapse. Claims that the model is struggling are not supported by current data.
Independent DPC physicians are opposed to working with NPs and PAs	DPC Alliance membership requires being a physician, medical student or resident, and its events are physician-only.⁷ The AAFP states NPs should not function as independent practitioners.⁸ A member of the DPC Alliance survey committee co-authored a book critical of NP and PA expansion.^6,9 Counterpoints: the book's co-author employs an NP in her own practice, and some state DPC laws explicitly include NPs and PAs.^9,10	Partly supported. The evidence shows a documented professional position on independent NP practice rather than a measured attitude toward NPs and PAs. The stronger explanation is structural: a solo micro-practice with no staff has no room for an NP or PA regardless of attitude.

Discussion

CMT's position

For this series, DPC is out of scope. The NP and PA series defines its subject as "concierge and membership-based medicine, excluding direct primary care," for three factual reasons. DPC's organized professional community is physician-only by charter.⁷ Its independent practices are predominantly staff-light micro-practices.⁶ And its employer-facing segment has largely become corporate advanced primary care.² None of those facts is a criticism. Each simply makes DPC a different subject.

For CMT overall, DPC stays in coverage. CMT covers the full landscape of membership-based care. DPC physicians are building sustainable, relationship-driven practices, which is exactly what CMT exists to report on. Removing the model from coverage would contradict CMT's commitment not to promote one model over another.

Notes on data and language

The best national data combine concierge and DPC. Zhu et al. (2025) report concierge and DPC practices as one category.³ As a result, NP and PA figures for concierge practices alone are not yet available, and CMT reports the combined figures with that label.

Language. CMT describes the differences between DPC and other membership models in terms of professional commitments and practice structures. That framing is accurate and reflects CMT's standard of respecting every practice model and profession it covers.

Consistency with Brief No. 18. Brief No. 18 treated NP- and PA-owned membership practices, including some that use a DPC-style fee structure, as a legitimate part of the field. This brief does not change that. It defines the scope of one series; it does not rank models or professions.

Figure 21.1. How CMT maps the membership landscape for this series

Scope decisions for the NP and PA series, with the evidence behind each.

Model	Typical structure	NP/PA fit, based on evidence	In this series?
Concierge (retainer plus insurance)	Physician-led, often Medicare-participating; many hybrid designs³	Growing APC share; team design possible	Included
Hybrid membership practices	Mix of membership fees and billing; includes corporate-affiliated groups	APC share rising across the sector¹¹	Included
NP- and PA-owned membership practices	Varies by state scope-of-practice law¹⁰	Legitimate and growing; limited outcome data	Included
Independent DPC	Physician-owned micro-practice; over 30% with no staff⁶	Little structural room for APCs	Separate subject
Employer-facing DPC and advanced primary care	Corporate onsite and near-site centers²	Operationally strong fit⁴	Separate subject

Evidence of fitStructural limits

Methods and limitations

How this position was reached

Design

Assumptions were tested against association membership rules, association policy statements, a national DPC practice survey, industry transaction reporting, a legal 50-state survey and peer-reviewed literature. Searches were conducted September 25, 2026.

Limitations

DPC practice counts vary by source: the DPC Coalition cites more than 2,300 practices, while the DPC Alliance survey estimated about 3,600.^1,6 The DPC Alliance survey reached about 13% of practices and may not be representative. The employer-clinic staffing data date from 2019. No longitudinal data on DPC practice closures were located. Attitudes of individual DPC physicians toward NPs and PAs have not been measured directly; this brief relies on association policies and practice structure instead.

Research support

Literature searches for this brief were supported by AI-assisted research tools. Every statistic is tied to the cited source, and derived figures are labeled. Concierge Medicine Today does not accept vendor sponsorship in exchange for coverage.

Cite as: Concierge Medicine Today Editorial Research Desk. The DPC Question: Why CMT's NP and PA Series Treats Direct Primary Care Separately. CMT Research Brief No. 21. Concierge Medicine Today, LLC; September 2026. Available at https://conciergemedicinetoday.net/dpc-editorial-position

Disclaimer

This research brief is published by Concierge Medicine Today, LLC for educational and informational purposes only. It does not constitute medical, legal, financial, tax or accounting advice, and it should not be relied upon as such. Scope-of-practice rules, corporate practice of medicine doctrines, title-disclosure requirements, Medicare participation and concierge fee arrangements, and consumer-protection rules for membership agreements vary by state and jurisdiction and change frequently. Consult qualified legal, regulatory and financial professionals before making practice decisions.

Concierge Medicine Today is an independent leadership publication and industry convener. It does not endorse any practice model, company or vendor, and it does not disparage other models of care or other professions. References to organizations are informational and do not imply endorsement by or of those organizations.

Statistics are reported as published by the cited sources. Where CMT has derived, rounded or inferred a figure, the brief says so. Readers should consult original sources before citing any figure. Corrections are made openly: if you identify an error, contact the editors and it will be acknowledged and corrected.

References

Direct Primary Care Coalition. Home page. dpcare.org
MobiHealthNews. Everside Health, Marathon Health announce merger. February 2024. mobihealthnews.com; Healthcare IT Today, merger close. March 1, 2024. healthcareittoday.com
Zhu JM, et al. Growth in number of practices and clinicians participating in concierge and direct primary care, 2018 to 2023. Health Affairs. December 2025. doi:10.1377/hlthaff.2025.00656. healthaffairs.org; PubMed
SHRM. The pros, cons and possibilities of onsite health care (citing the National Business Group on Health 2019 Large Employers' Health Care Strategy and Plan Design Survey). shrm.org
Direct primary care: family physician perceptions of a growing model. Population Medicine. 2021. PubMed
Bernard R. Five surprising findings about the state of direct primary care (DPC Alliance 2024 survey). Medical Economics. July 29, 2026. medicaleconomics.com
Direct Primary Care Alliance. Memberships (eligibility and physician-only events). dpcalliance.org
American Academy of Family Physicians. Scope of practice: nurse practitioners (background paper). aafp.org
Al-Agba N, Bernard R. Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Universal Publishers; 2020. Referenced in AMA House of Delegates Resolution 218 (N-21): ama-assn.org. Author interview noting an NP in her practice: player.fm
McDermott Will and Schulte. Direct primary care arrangements: 50-state survey. July 2026. mcdermottlaw.com
MGMA. Snapshot: reactions and responses to the growth in concierge and direct primary care. December 30, 2025. mgma.com