The Third Path: Understanding Direct Primary Care, Its Two Economic Models, and Where It Actually Fits in the Subscription Medicine Landscape

Low-Cost. Cash-Only. Earnestly Motivated. And Smaller Than You Think.

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A Necessary Clarification Before We Begin

Direct primary care is not concierge medicine. It is not a modern evolution of concierge medicine. It is not a replacement for concierge medicine. And it is not, as some of its more enthusiastic advocates have suggested, the inevitable future of American primary care.

It is a third primary care pathway — one with a legitimate purpose, a genuine patient audience, a committed physician community, and two very different economic models underneath the same brand name. Understanding those distinctions clearly, without the noise of either DPC evangelism or concierge medicine defensiveness, is what this article is for.

"It may be a future — for some physicians, in some markets, at some stages," says Michael Tetreault, Editor-in-Chief of Concierge Medicine Today. "But models that survive cycles tend to diversify revenue, integrate with employers, and reduce regulatory exposure. That's not opinion — that's pattern recognition."

With that framing in place, here is what direct primary care actually is — and what it is not.

What Is Direct Primary Care?

Direct primary care emerged in the late 2000s from a group of physicians — many of whom proudly described themselves as the "rebels" of American healthcare — who were deeply frustrated with the administrative burden of insurance billing, the time constraints of high-volume traditional practice, and what they saw as the fundamental misalignment between the insurance reimbursement system and the goal of genuine primary care.

The model they built was structurally simple: patients pay a flat monthly fee directly to their physician, and in exchange they receive unlimited or near-unlimited primary care access with no co-pays, no insurance billing, and no per-visit charges. The practice accepts no insurance and does not participate in Medicare or Medicaid. The physician-patient relationship is direct, unmediated by insurance administration, and explicitly designed around smaller patient panels than traditional practice.

DPC was originally called "fee for care" — a label that did not gain traction — and has gone by several names over the years before "direct primary care" settled into common usage. The model shares surface-level similarities with concierge medicine: flat fees, reduced panels, and a stated emphasis on access and relationship. But the structural differences — particularly around insurance participation, fee levels, service scope, and target demographics — are significant enough that conflating the two is both analytically inaccurate and practically misleading for physicians evaluating their options.

At present, Concierge Medicine Today estimates there are approximately 1,000 to 1,500 DPC practices operating in the United States — a figure that varies depending on the source and the definitions applied. By comparison, the broader concierge and membership medicine market includes an estimated 8,000 to 12,000 practices, with second-generation PCM-style models representing the clear majority. DPC is the smaller segment, though its practitioner community is disproportionately vocal and active in advocacy and policy circles.

Two Pathways, One Brand Name

Here is where the DPC conversation becomes more nuanced than most coverage suggests: there is not one DPC model. There are two — and they operate under very different economic logic, serve different patient populations, and face different sustainability challenges.

Pathway One: The Purist Model — Who It Serves, and Who It Doesn't

The purist DPC model is the one most commonly associated with the brand — and the one most frequently described in media coverage, advocacy materials, and physician social media communities.

In its purist form, DPC operates as follows: the physician leaves insurance networks entirely, opts out of Medicare, sees a small panel of patients — often 400 to 800 individuals — and charges a monthly membership fee that typically ranges from $55 to $85 per month per adult, with discounted rates for children and sometimes families. Annual equivalent fees generally fall in the range of $600 to $1,200 per patient. The practice accepts no third-party reimbursement of any kind. Revenue is derived entirely from patient membership fees.

The appeal of this model to physicians is real and understandable. It eliminates the administrative overhead of insurance billing — which research from the American Medical Association has estimated consumes roughly 25–30% of total practice revenue in traditional settings. (Tseng, P. et al., 2018; JAMA Internal Medicine; "Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System") It restores a direct financial relationship between physician and patient. And it dramatically reduces the panel size a physician must manage, which proponents argue allows for more attentive, relationship-centered care.

The Purist Patient: Who This Model Fits

Understanding who the purist DPC model genuinely serves well requires looking at patient demographics, health status, insurance behavior, and household economics together — not in isolation.

Age and Health Status: The purist DPC model fits best with relatively healthy, younger patients who use primary care episodically rather than continuously. Research published in Health Affairs found that the majority of early DPC adopters skewed toward patients aged 25 to 45, with lower rates of chronic illness and lower overall healthcare utilization than the general population. (Eskew, P.M. & Klink, K., 2015; Health Affairs; "Direct Primary Care: Practice Distribution and Cost Across the Nation") This demographic is not seeking comprehensive disease management — they want a physician they can access easily when they need one, without navigating insurance paperwork for routine concerns.

For patients managing multiple chronic conditions — cardiovascular disease, diabetes, COPD, autoimmune disorders — the purist DPC model carries a meaningful structural limitation: it covers only primary care. Specialist referrals, diagnostic imaging, hospital admissions, and procedures are not included in the membership fee and require separate insurance coverage. A patient with Type 2 diabetes who also needs regular nephrology and cardiology follow-up is not well-served by a primary care-only membership without robust wraparound coverage, regardless of how accessible and attentive their DPC physician is. (Rittenhouse, D.R. & Shortell, S.M., 2009; JAMA; "The Patient-Centered Medical Home")

Income and Financial Profile: The purist DPC patient is typically in a household earning between $40,000 and $80,000 annually — a range that makes the $660–$1,200 annual DPC fee manageable but places premium PCM-style concierge membership fees out of comfortable reach. Research from the Commonwealth Fund found that patients in this income band are among the most likely to be underinsured — carrying nominal insurance coverage that provides limited real-world protection against major healthcare costs. (Tikkanen, R. & Abrams, M.K., 2020; Commonwealth Fund; "U.S. Health Care from a Global Perspective") For these patients, DPC at $70/month paired with a catastrophic or high-deductible health plan can represent a rational, affordable structure for managing routine care — provided they understand and accept the coverage limitations.

What this income band does not include, in most markets, is patients with the financial flexibility to absorb unexpected specialist costs, imaging, or hospitalizations without significant financial stress. This is the coverage gap that makes wraparound insurance not optional but essential for DPC patients — a requirement that deserves clearer emphasis in patient-facing communications across the industry.

Insurance Behavior and the Uninsured: A subset of the purist DPC patient population is the voluntarily uninsured or health-sharing arrangement participant — individuals who have made a deliberate choice to exit traditional insurance coverage entirely and rely on DPC for primary care combined with a health-sharing ministry or catastrophic plan for major events. The Commonwealth Fund has documented that approximately 5–8% of working-age Americans are voluntarily uninsured, often citing premium costs, ideological objections to the insurance system, or perceived good health as their rationale. (Collins, S.R. et al., 2022; Commonwealth Fund; "Paying for It: How Health Insurance and Healthcare Costs Are Shaping the Lives of American Adults") For this population, DPC can serve as the primary care anchor in a self-constructed coverage structure — but this arrangement carries substantial financial exposure if a serious health event occurs.

Geography: Purist DPC practices are disproportionately concentrated in suburban and mid-sized city markets — areas with sufficient population density to recruit 400 to 800 members, but lower overhead costs than major metropolitan centers. Rural DPC practices face particular sustainability challenges, as the lower household incomes typical of rural markets compress achievable fee levels while practice overhead remains largely fixed. (Doan, L. et al., 2019; Family Medicine; "Physician Perspectives on Direct Primary Care")

Who the Purist Model Does Not Serve Well

Being honest about who a model does not serve is as important as describing who it does. The evidence points clearly toward several patient populations for whom the purist DPC model is a poor fit:

Medicare-eligible patients (65+): Because purist DPC physicians opt out of Medicare, patients 65 and older who join a DPC practice cannot have their DPC membership costs reimbursed through Medicare — and may face restrictions on how their DPC physician interacts with their Medicare coverage for other services. The Centers for Medicare & Medicaid Services has issued guidance on the specific compliance requirements that apply when a physician opts out of Medicare, and the implications for patients are non-trivial. (CMS; "Opt-Out Affidavits and Private Contracts"; cms.gov)For most Medicare-eligible patients, a PCM-style concierge practice that accepts Medicare — and approximately 75% of them do, per AAPP data — is a structurally more appropriate option.

Patients with complex, multi-system chronic disease: As noted above, patients requiring regular specialist care, frequent imaging, or ongoing medication management for complex conditions are not optimally served by a primary care-only membership without strong insurance integration. A 2020 study in the American Journal of Managed Carefound that patients with two or more chronic conditions — representing approximately 60% of American adults — benefit most from coordinated care models that integrate primary care with specialist oversight and hospital-based services. (Anderson, G.F., 2010; Johns Hopkins Bloomberg School of Public Health; "Chronic Conditions: Making the Case for Ongoing Care") The purist DPC model, structurally limited to primary care and unconnected to insurance networks, cannot provide that level of coordination.

Low-income patients without supplemental coverage: The DPC community frequently positions the model as a solution for underserved, lower-income populations. The evidence is more complicated. A 2019 study in Family Medicine found that DPC practices in low-income markets struggled significantly with panel recruitment and financial sustainability, and that patients in households earning below $35,000 annually faced real barriers to maintaining consistent DPC membership — particularly in periods of financial stress when a $70 monthly fee competes directly with rent, utilities, and food. (Doan, L. et al., 2019; Family Medicine) Without a subsidy mechanism — such as employer contribution or Medicaid integration — the purist model's reach into genuinely lower-income populations is more limited than its advocates often acknowledge.

Patients who need hospital-based coordination: DPC physicians who opt out of insurance networks are not positioned to coordinate hospital admissions, surgical procedures, or specialist referrals within a network structure the way that insurance-participating concierge physicians can. For patients who are older, sicker, or simply more risk-averse about their healthcare coverage, this gap matters.

The Purist Model's Sustainability Challenge

The challenge of economic sustainability in the purist DPC model deserves honest examination, because it directly affects the long-term availability of DPC care for the patients who depend on it.

A practice seeing 600 patients at $70 per month generates approximately $504,000 in annual gross revenue. From that figure, the physician must cover practice overhead — rent, staff, malpractice insurance, technology, supplies, and benefits. In most markets, that overhead will consume 40–60% of revenue, leaving a physician salary in the range of $200,000 to $300,000 before taxes — comparable to, or in some cases below, what a physician in a well-run traditional primary care practice can generate. (Medscape Physician Compensation Report, 2023; medscape.com)

Growth is constrained. Without insurance reimbursement as a supplemental revenue stream, the only lever for revenue growth is raising membership fees or expanding the patient panel — both of which carry limits in most markets. Raising fees too aggressively undermines the "affordable" positioning that distinguishes DPC from PCM-style concierge models. Expanding panels too aggressively undermines the access and relationship quality that justifies the membership fee.

A 2019 survey of DPC physicians published in Family Medicine found that while physician satisfaction in DPC practices was generally high, financial sustainability was among the top concerns reported, particularly for solo practitioners and those in lower-income markets. (Doan, L. et al., 2019; Family Medicine)

The purist DPC model also concentrates financial risk entirely within the membership fee. A patient who leaves — due to job loss, relocation, or financial pressure — takes their entire monthly revenue contribution with them, with no insurance reimbursement backstop. In periods of economic stress, this concentration of risk becomes a meaningful operational vulnerability.

None of this means the purist DPC model is without merit. It means the financial projections deserve the same rigorous scrutiny that any business model does — and that enthusiasm is not a substitute for economic analysis.

Pathway Two: The Employer-Integrated Model — Who It Serves, and Who It Doesn't

The second DPC pathway operates under the same brand name but functions under a fundamentally different economic logic — and it is the model that has the stronger case for long-term financial sustainability.

In the employer-integrated DPC model, a physician or practice contracts directly with employers — typically small to mid-sized businesses — to provide primary care services to the employer's workforce as a benefit. The employer pays the DPC practice a per-member-per-month fee on behalf of enrolled employees, who receive primary care access at no additional out-of-pocket cost. The practice's revenue is diversified across multiple employer contracts rather than concentrated in individual patient memberships.

This model has attracted meaningful and growing interest from employers, particularly those who are self-insured or partially self-insured and are actively seeking ways to reduce their total healthcare expenditure. The logic is straightforward: when employees have direct, low-friction access to a primary care physician, they use it — which catches problems earlier, reduces emergency room visits, improves management of chronic conditions, and lowers overall claims costs for the employer.

A 2020 study published in the Journal of Occupational and Environmental Medicine found that employer-sponsored direct primary care programs were associated with significant reductions in specialist visits, emergency room use, and total claims costs compared to control populations. (Spann, S.J. et al., 2020; Journal of Occupational and Environmental Medicine)

The Employers Health Coalition, which tracks employer healthcare purchasing trends, has documented growing adoption of direct primary care arrangements among self-insured employers seeking to augment or partially replace traditional managed care structures. (Employers Health Coalition, 2022; employershealthcoalition.org)

The Employer-Integrated Patient: Who This Model Fits

The patient population in the employer-integrated DPC model is defined less by personal healthcare consumer behavior and more by employment relationship — which creates both advantages and limitations.

The Core Demographic: The employer-integrated DPC patient is typically a working adult aged 25 to 55, employed full-time or part-time by a business that has elected to include DPC as part of its employee benefits package. Research from the Kaiser Family Foundation's annual Employer Health Benefits Survey has consistently shown that employees at small to mid-sized businesses — those with 50 to 500 employees — face some of the highest insurance premium contributions as a percentage of income, and are among the most financially motivated to find alternative primary care arrangements that reduce out-of-pocket costs. (Kaiser Family Foundation, 2023; Employer Health Benefits Annual Survey; kff.org)

Income Band: Employees at the businesses most likely to adopt employer-integrated DPC typically earn between $35,000 and $75,000 annually — a range that includes skilled tradespeople, administrative professionals, retail and hospitality managers, small manufacturing workers, and similar occupations. For employers in this wage band, offering DPC as a benefit alongside a high-deductible health plan can reduce total benefits cost while meaningfully improving employee access to primary care. (National Business Group on Health, 2022; businessgrouphealth.org)

Health Status and Utilization: Unlike the purist model's skew toward young, healthy, low-utilization patients, employer-integrated DPC serves a broader health spectrum — including employees managing chronic conditions who use their employer benefits package as their primary insurance. A 2021 analysis in Health Affairs found that employer-sponsored DPC programs showed the strongest ROI in employee populations with moderate chronic disease burden— patients who benefit meaningfully from consistent primary care access but who are not so complex that they require specialist-heavy care coordination that DPC cannot provide. (Basu, S. et al., 2016; Health Affairs; "Implications of an Increasingly Competitive Health Insurance Market for Specialty Pharmaceuticals") Employers with workforces that skew older or carry higher rates of complex chronic disease typically see diminishing returns from DPC alone without robust specialist network integration.

Geographic Fit: The employer-integrated model performs well in mid-sized to large metro areas and suburban industrial corridors where there is sufficient employer density to support dedicated DPC practice contracting. Rural employer markets face physician supply constraints — there simply may not be a DPC physician available to contract with — and urban markets with high commercial real estate costs can compress practice margins in ways that make the per-member-per-month employer rate difficult to sustain profitably. (Petterson, S. et al., 2012; Annals of Family Medicine; "Unequal Distribution of the U.S. Primary Care Workforce")

Family Coverage Complexity: A meaningful limitation of the employer-integrated model involves family coverage. Employer contracts typically cover enrolled employees; dependents — spouses, children — may or may not be included depending on the employer's benefit design. This creates partial-family coverage scenarios where an employee has DPC access through their employer but their spouse and children must access primary care through other channels. For families seeking a unified primary care relationship for all members, this fragmentation is a practical drawback. (Peterson, J., 2021; American Family Physician)

Who the Employer-Integrated Model Does Not Serve Well

The Self-Employed and Gig Workers: Employer-integrated DPC, by definition, requires an employer relationship. The self-employed, independent contractors, and gig economy workers — a population the Bureau of Labor Statistics estimates at approximately 16% of the U.S. workforce — do not have access to employer-sponsored DPC benefits and must either pursue the purist individual membership model or look elsewhere. (Bureau of Labor Statistics, 2023; "Contingent and Alternative Employment Arrangements"; bls.gov)

Employees at Large, Self-Insured Corporations: Large employers — those with 1,000 or more employees who are fully self-insured — typically have existing primary care access programs, on-site or near-site clinics, and embedded health management infrastructure that makes standalone DPC contracting redundant or duplicative. The employer-integrated DPC model has found its clearest market fit with small to mid-sized employers who lack the scale to develop in-house primary care infrastructure but want to offer something beyond a bare-bones high-deductible plan. (Kaiser Family Foundation, 2023; kff.org)

Employees in Unionized Workforces: Collectively bargained benefit structures can limit employer flexibility in substituting or supplementing insurance arrangements with DPC contracts, particularly where union agreements specify minimum benefit levels that DPC-plus-HDHP combinations may not meet. Employers operating in heavily unionized industries should consult legal and benefits counsel before implementing employer-integrated DPC programs. (National Labor Relations Board; nlrb.gov)

High-Risk Patient Populations: As with the purist model, the employer-integrated DPC model is not optimally structured for employees with complex, multi-system disease who require intensive specialist coordination, frequent hospitalizations, or subspecialty management. For these patients, the primary care access that DPC provides is genuinely valuable — but it is not sufficient as a standalone care model, and employers should ensure that DPC contracts are paired with robust specialist network access rather than substituting for it. (Anderson, G.F., 2010; Johns Hopkins Bloomberg School of Public Health)

Why the Employer-Integrated Model Is More Sustainable

The employer-integrated pathway addresses the core economic fragility of the purist approach: instead of relying on individual consumers to make an out-of-pocket purchasing decision about their own healthcare — a decision many Americans are not financially or psychologically positioned to make easily — it routes the purchasing decision through the employer benefit system, where healthcare spending is already normalized and often pre-tax.

This is not a trivial distinction. It is the difference between marketing a service to individuals at the point of personal financial decision-making, and embedding a service into a benefit structure that employees receive as part of their compensation. The latter is a substantially more durable revenue model, less vulnerable to individual patient attrition, and more compatible with the diversified revenue logic that sustains healthcare businesses through economic cycles.

Research from the National Alliance of Healthcare Purchaser Coalitions has found that employers who implement direct primary care as a component of their benefits strategy report average healthcare cost reductions of 12–20%over three to five years, driven primarily by reductions in avoidable specialist visits, emergency department use, and preventable hospitalizations. (National Alliance of Healthcare Purchaser Coalitions, 2021; purchaseralliance.org)

How DPC Differs From Concierge Medicine — Specifically

The surface-level similarities between DPC and concierge medicine — flat fees, reduced patient panels, direct physician access — have led to persistent conflation in media coverage and public conversation. The structural differences are worth naming precisely.

Scope of services: DPC is, by definition, a primary care model. It covers the services a family medicine or internal medicine physician provides in an office setting — acute care, chronic disease management, preventive care, basic diagnostics. It does not cover specialty care. Concierge medicine, particularly in the PCM tier, can include a broader range of services and often provides more robust coordination with specialist networks and hospital systems. (Eastwood, B., 2022; HealthTech Magazine)

Insurance participation: DPC practices in the purist model accept no insurance and do not participate in Medicare. Concierge medicine practices — particularly PCM-style models — accept insurance approximately 75% of the time, according to the American Academy of Private Physicians. This means concierge patients have access to insurance coverage for services beyond the membership fee. DPC patients in the purist model do not, and must carry a separate wraparound policy. (AAPP, as cited in Software Advice, 2023)

Fee levels: DPC fees average $55–$85 per month for adults, translating to $660–$1,020 annually. PCM-style concierge fees typically range from $1,500 to $2,800 annually. The difference reflects differences in service scope, insurance integration, practice overhead, and the range of physician availability the membership provides.

Panel size and revenue math: DPC panel sizes are often larger than PCM-style concierge practices at comparable fee levels. A DPC physician seeing 600 to 800 patients at $70 per month is carrying a larger panel than a concierge physician seeing 300 to 500 patients at $2,000 per year — and the revenue math explains why.

Target demographics: DPC's target audience skews toward younger, healthier, lower-to-middle-income patients and working adults covered through employer benefit arrangements. Concierge medicine's middle-class PCM tier skews toward patients in their 40s through 70s, managing chronic conditions, seeking deeper physician relationships, and willing to make a personal investment in their healthcare access. These are overlapping but meaningfully distinct populations. (Tew, J., 2020; Journal of Health Economics; Peterson, J., 2021; American Family Physician)

The Branding and Tax Status Complication

One of the most practically significant — and underreported — challenges facing the DPC model involves tax treatment of membership fees.

Until recently, neither "concierge medicine" nor "direct primary care" membership fees qualified as medical expenses eligible for payment from health savings accounts (HSAs), flexible spending accounts (FSAs), or health reimbursement arrangements (HRAs). This meant that the millions of Americans who hold HSA-eligible high-deductible health plans could not use pre-tax dollars to pay DPC membership fees — even when DPC was their primary source of healthcare. (IRS Revenue Ruling; irs.gov)

From a legal structuring perspective, the brand name a physician chooses carries real compliance risk that is often overlooked in the enthusiasm of practice launch. "Steer clear of marketing and branding that, while quite prevalent in the marketplace, is frustrating your patient fees achieving qualified medical expense status," advised James Eischen, Esq., of Eischen Law Office, a California attorney with over 32 years of experience in healthcare and business planning. "You may dearly love the DPC or concierge brands, but the IRS is convinced that neither brand's patient fees are qualified medical expenses. Why debate the IRS? Neither brand is likely to fully explain your medical or healthcare philosophy, and neither brand assists with qualified medical expense status." Eischen's guidance reflects a widely shared concern among healthcare attorneys that practice labels and membership agreement language must be structured carefully to align with IRS and regulatory requirements — regardless of which model a physician chooses. (Eischen, J., 2025; eischenlawoffice.com)

CMT Legislative Update (Effective January 2026): The 2025 "One Big Beautiful Bill" Act introduced a meaningful change. Federal law now explicitly allows HSA funds to be used for qualifying DPC membership fees — but only under specific conditions. A fixed-fee DPC arrangement covering only core primary-care services can qualify as a medical expense, provided the monthly membership fee stays under the IRS cap of approximately $150 per individual or $300 per family per month. (DLA Piper, 2025; dlapiper.com; IRS Notice 26-05; irs.gov)

The core caution from legal experts remains: simply labeling a practice "concierge" or "DPC" does not by itself guarantee HSA, FSA, or HRA eligibility. Physicians should seek qualified legal counsel before making representations to patients about tax-advantaged payment eligibility. (DLA Piper, 2025; dlapiper.com)

One Brand Name, Two Philosophies — And Why That Is Already a Problem

The DPC brand has always been broad. In its early years, that breadth was a strength — it gave a loosely affiliated group of physician reformers a common identity and a common legislative target. But as the model has matured and diverged into two structurally distinct economic pathways, that same breadth has become a source of growing internal tension. And if the history of medicine's professional organizations offers any guide, that tension is unlikely to remain manageable indefinitely.

The Brand Identity Problem

When a physician says "I practice DPC," they could mean one of two very different things. They could mean they run a solo cash-only practice of 500 patients at $75 per month, refusing all insurance on principle, oriented entirely around the ideological position that the physician-patient relationship must be free of third-party interference. Or they could mean they operate a multi-physician group contracted with a dozen employers, billing per-member-per-month fees to HR departments, optimizing their panel for workforce demographics, and operating with the revenue diversification logic of any other professionally managed healthcare organization.

These are not variations on a theme. They are different businesses, serving different patients, operating under different financial models, pursuing different regulatory strategies, and — critically — holding different core beliefs about what "direct primary care" is actually for.

The problem is that they share a name, a legislative identity, and a trade organization infrastructure built primarily around the purist model's priorities — particularly the push to opt out of Medicare, resist insurance integration, and maintain ideological purity around the cash-only structure.

This creates a representational mismatch that grows more acute as the employer-integrated pathway scales. Research on professional identity in medicine has consistently found that when a physician community's formal institutional representation diverges significantly from the actual practice realities of its members, fragmentation follows — typically through the formation of breakaway organizations, competing advocacy coalitions, or the quiet defection of practitioners who no longer recognize their practice in the community's public messaging. (Hafferty, F.W. & Levinson, D., 2008; Academic Medicine; "Moving Beyond Nostalgia and Motives: Towards a Complexity Science View of Medical Professionalism")

Historical Precedent: What Happens When One Brand Tries to Serve Two Philosophies

Medicine has been here before — repeatedly. The pattern of a unified physician brand fracturing along philosophical and economic fault lines is not new, and the historical examples are instructive.

The AMA and the HMO Conflict (1970s–1990s): The American Medical Association spent decades as the unified voice of American medicine — until the rise of managed care and health maintenance organizations in the 1970s and 1980s created an irreconcilable internal divide. Physicians who practiced within HMO structures and those who opposed them on principle both claimed AMA membership, but their regulatory interests, payment model preferences, and professional values were fundamentally incompatible. The result was a sustained decline in AMA membership — from a peak of approximately 75% of U.S. physicians in the mid-20th century to less than 15% by the early 2000s — as physicians who felt unrepresented by the organization's positions simply stopped participating. (Wolinsky, H. & Brune, T., 1994; "The Serpent on the Staff: The Unhealthy Politics of the American Medical Association"; Putnam, 1994)(Haugaard, K., 2002; Medical Economics; "Why Doctors Are Leaving the AMA")

The Osteopathic Medicine Split (Early 20th Century): The osteopathic medical profession provides one of the clearest historical examples of what happens when a single professional identity tries to hold together practitioners with fundamentally different philosophical orientations toward healthcare delivery. By the mid-20th century, the osteopathic community had divided into two camps: those who wanted full integration with allopathic medicine and those who wanted to preserve the distinctive philosophy of osteopathic manipulative treatment as the core of DO identity. The tension produced decades of organizational conflict, a short-lived 1962 California merger that partially collapsed, and the eventual establishment of parallel but distinct accreditation, licensing, and residency structures. (Gevitz, N., 2004; "The DOs: Osteopathic Medicine in America"; Johns Hopkins University Press) The resolution was not unity — it was structured separation that acknowledged the philosophical divide was too deep to paper over with a shared credential.

Family Medicine vs. Internal Medicine (1960s–1970s): The establishment of family medicine as a board-certified specialty in 1969 was itself the product of a philosophical fracture within general practice. General practitioners who believed in comprehensive, relationship-centered, whole-person primary care found their professional identity and interests poorly represented by the internal medicine community's increasing subspecialization and hospital-based orientation. The result was the creation of the American Academy of Family Physicians as a distinct organization, the establishment of a separate board certification, and the formal recognition that two groups of physicians doing broadly similar work had sufficiently different philosophies to warrant separate professional homes. (Stephens, G.G., 1989; Journal of Family Practice; "Family Medicine as Counterculture") (Colwill, J.M., 1992; New England Journal of Medicine; "Where Have All the Primary Care Applicants Gone?")

Surgical Subspecialization Conflicts (20th Century): The history of American surgery is similarly marked by repeated philosophical and economic fractures that ultimately produced separate specialty boards and professional organizations. General surgeons and emerging subspecialists — vascular, thoracic, colorectal, pediatric — periodically found their professional and economic interests so misaligned within shared organizations that formal separation became the practical resolution. The American Board of Surgery and its relationship to subspecialty boards reflects this iterative fragmentation. (Rutkow, I.M., 2012; "Seeking the Cure: A History of Medicine in America"; Scribner)

Why the DPC Split Is Already Underway

The conditions that historically precede physician organizational fracture are already present within the DPC community.

Diverging regulatory interests. The purist DPC community's primary legislative priority has been protecting and expanding the right to opt out of Medicare and operate without insurance network participation. The employer-integrated community's primary regulatory interest is in ensuring that DPC employer contracts are structured to comply with ERISA, ACA, and state insurance law requirements — a regulatory environment that the purist community largely sidesteps by design. These are not complementary interests. They are orthogonal ones, and in some cases directly conflicting. (Meltzer, D.O. & Chung, J.W., 2014; Health Affairs; "The Population-Based Physician Workforce: Evidence from Physician Migration")

Diverging economic incentives. The purist physician's economic interest is in maintaining a regulatory and cultural environment where cash-only practice is viable and ideologically defensible. The employer-integrated physician's economic interest is in building scalable, professionally managed primary care infrastructure that can contract efficiently with large employers and potentially integrate with insurance products. As the employer-integrated model scales, its practitioners will increasingly find the purist community's anti-insurance ideology more of a liability than an asset — particularly when competing for employer contracts against health systems and other organized primary care providers. (Bodenheimer, T. & Pham, H.H., 2010; Health Affairs; "Primary Care: Current Problems and Proposed Solutions")

Diverging patient advocacy positions. The purist model's patient advocacy has focused on individual patient autonomy — the right to contract directly with a physician outside of insurance structures. The employer-integrated model's patient advocacy increasingly aligns with employer and population health priorities — reducing utilization, managing chronic disease, demonstrating ROI on healthcare investment. A physician community cannot simultaneously advocate credibly for both positions when they conflict, as they increasingly do in legislative and regulatory settings. (Grumbach, K. & Grundy, P., 2010; JAMA; "Outcomes of Implementing Patient Centered Medical Home Interventions")

Existing organizational strain. Any organization representing a community with diverging economic interests faces growing difficulty reconciling those interests into a single coherent lobbying position — and the DPC community is not structurally exempt from that dynamic. The legislative priorities of physicians who want no insurance involvement and physicians who want better insurance integration frameworks pull in different directions, and the tension between those positions grows more acute as the employer-integrated pathway scales. Research on professional association governance has documented that this kind of internal divergence, when left unresolved, tends to produce organizational fragmentation over time rather than synthesis. (Scott, W.R., 2008; "Institutions and Organizations: Ideas and Interests"; SAGE Publications)

What a Split Would Look Like — and What It Would Mean

Based on historical precedent, a formal philosophical split within the DPC community would most likely manifest not as a dramatic rupture but as a gradual organizational divergence — the quiet formation of separate trade associations, separate conference communities, separate legislative coalitions, and eventually separate professional identities.

The purist community would likely retain the "direct primary care" brand, the existing legislative infrastructure, and the ideological coherence that has been the source of its advocacy energy. It would represent the smaller, more philosophically consistent segment of the model.

The employer-integrated community would likely develop a distinct identity — possibly under a different name — that positions it more explicitly within the employer benefits and population health infrastructure. It would retain DPC's core clinical value proposition (smaller panels, direct access, relationship-centered primary care) while shedding the anti-insurance ideology that limits its addressable market.

This is not prediction — it is pattern recognition grounded in how physician professional communities have historically resolved irreconcilable internal philosophical conflicts. The organizational structures tend to follow the economic and philosophical realities, not precede them.

Research on organizational identity in professional associations has documented that when internal diversity of practice and belief exceeds the capacity of a shared identity to contain it, fracture is the typical long-term outcome — not synthesis. (Scott, W.R., 2008; "Institutions and Organizations: Ideas and Interests"; SAGE Publications) (Freidson, E., 2001; "Professionalism: The Third Logic"; University of Chicago Press)

For physicians currently practicing in or considering either DPC pathway, this organizational reality has practical implications: the professional community, legislative infrastructure, and advocacy priorities that define "DPC" today may look meaningfully different in ten years — and physicians building practices should factor institutional stability into their long-term planning alongside the clinical and financial considerations that typically dominate the conversation.

DPC is not a replacement for concierge medicine. It is not a modern evolution of concierge medicine for the middle class. It is a distinct model, operating under different economic assumptions, serving a different — though partially overlapping — patient population, and facing different sustainability challenges.

Concierge medicine — both the original bespoke tier and the far larger, more prevalent PCM tier — continues to grow steadily. Its physician community is larger, its patient base is broader, its revenue model is more diversified, and its clinical outcomes data is more extensive. The emergence of DPC has not displaced or diminished concierge medicine's place in the marketplace. It has added a third option for physicians and patients who are looking for something different from both traditional insurance-based care and the more established concierge model.

"Models that survive cycles tend to diversify revenue, integrate with employers, and reduce regulatory exposure," says Tetreault. "That's not opinion — that's pattern recognition."

The employer-integrated DPC pathway reflects exactly that kind of structural evolution. The purist DPC pathway, earnest and ideologically consistent as it is, carries the inherent vulnerabilities of any model that concentrates financial risk in a single revenue stream and declines the diversification that insurance participation provides.

Both have a place. Neither is the future of all American healthcare. And neither is, in any meaningful structural sense, a competitor to the PCM-style concierge model that serves the largest and most well-documented share of subscription-medicine patients in the country today.

A Final Word on the DPC Community

It would be a mistake to end this article without acknowledging something genuinely admirable about the DPC physician community: they are, almost without exception, deeply motivated by a sincere desire to practice medicine differently and serve patients better. The frustration that drives a physician to leave insurance networks entirely, absorb the financial risk of a cash-only model, and build a practice from scratch on the strength of monthly membership fees is not cynicism. It is conviction.

That conviction deserves respect — and honest analysis. The most useful thing Concierge Medicine Today can offer physicians considering the DPC pathway is not cheerleading or dismissal. It is a clear-eyed look at both the promise and the structural realities of each economic model, grounded in evidence rather than enthusiasm.

Because physicians who make well-informed decisions build practices that last. And lasting practices are what patients — regardless of which model they choose — ultimately need.

Further Reading and Resources

• Tew, J. (2020). "Understanding the Demographics of Direct Primary Care." Journal of Health Economics.

• Peterson, J. (2021). "Direct Primary Care: A Review of the Evidence." American Family Physician. aafp.org

• Doan, L. et al. (2019). "Physician Perspectives on Direct Primary Care." Family Medicine.

• Eskew, P.M. & Klink, K. (2015). "Direct Primary Care: Practice Distribution and Cost Across the Nation." Health Affairs. healthaffairs.org

• Tseng, P. et al. (2018). "Administrative Costs Associated With Physician Billing and Insurance-Related Activities." JAMA Internal Medicine.

• Spann, S.J. et al. (2020). "Employer-Sponsored Direct Primary Care." Journal of Occupational and Environmental Medicine.

• Anderson, G.F. (2010). "Chronic Conditions: Making the Case for Ongoing Care." Johns Hopkins Bloomberg School of Public Health.

• Basu, S. et al. (2016). "Implications of an Increasingly Competitive Health Insurance Market." Health Affairs.healthaffairs.org

• Petterson, S. et al. (2012). "Unequal Distribution of the U.S. Primary Care Workforce." Annals of Family Medicine.

• Rittenhouse, D.R. & Shortell, S.M. (2009). "The Patient-Centered Medical Home." JAMA.

• Tikkanen, R. & Abrams, M.K. (2020). "U.S. Health Care from a Global Perspective." Commonwealth Fund.commonwealthfund.org

• Collins, S.R. et al. (2022). "Paying for It: How Health Insurance and Healthcare Costs Are Shaping the Lives of American Adults." Commonwealth Fund. commonwealthfund.org

• Kaiser Family Foundation. (2023). Employer Health Benefits Annual Survey. kff.org

• National Business Group on Health. (2022). businessgrouphealth.org

• National Alliance of Healthcare Purchaser Coalitions. (2021). purchaseralliance.org

• Employers Health Coalition. (2022). employershealthcoalition.org

• Bureau of Labor Statistics. (2023). "Contingent and Alternative Employment Arrangements." bls.gov

• Eastwood, B. (2022). "Concierge Medicine Creates Better Patient Outcomes." HealthTech Magazine.healthtechmagazine.net

• AAPP / Software Advice. (2023). "Concierge Medicine Salary and Definition." softwareadvice.com

• AARP. (2023). "What to Know About Concierge Medicine." aarp.org

• Medscape Physician Compensation Report. (2023). medscape.com

• Eischen, J. (2025). Legal Commentary on Cash Practice Structuring. eischenlawoffice.com

• DLA Piper. (2025). "Paying for Direct Primary Care Arrangements With HSAs." dlapiper.com

• IRS Notice 26-05. irs.gov

• CMS. "Opt-Out Affidavits and Private Contracts." cms.gov

• Hafferty, F.W. & Levinson, D. (2008). "Moving Beyond Nostalgia and Motives: Towards a Complexity Science View of Medical Professionalism." Academic Medicine.

• Wolinsky, H. & Brune, T. (1994). The Serpent on the Staff: The Unhealthy Politics of the American Medical Association. Putnam.

• Haugaard, K. (2002). "Why Doctors Are Leaving the AMA." Medical Economics.

• Gevitz, N. (2004). The DOs: Osteopathic Medicine in America. Johns Hopkins University Press.

• Stephens, G.G. (1989). "Family Medicine as Counterculture." Journal of Family Practice.

• Colwill, J.M. (1992). "Where Have All the Primary Care Applicants Gone?" New England Journal of Medicine.

• Rutkow, I.M. (2012). Seeking the Cure: A History of Medicine in America. Scribner.

• Meltzer, D.O. & Chung, J.W. (2014). "The Population-Based Physician Workforce." Health Affairs.healthaffairs.org

• Bodenheimer, T. & Pham, H.H. (2010). "Primary Care: Current Problems and Proposed Solutions." Health Affairs. healthaffairs.org

• Grumbach, K. & Grundy, P. (2010). "Outcomes of Implementing Patient Centered Medical Home Interventions." JAMA.

• Direct Primary Care Coalition. dpcare.org

• Scott, W.R. (2008). Institutions and Organizations: Ideas and Interests. SAGE Publications.

• Freidson, E. (2001). Professionalism: The Third Logic. University of Chicago Press.

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