How Direct Primary Care Works and How to Find a Practice That Offers It

Try this experiment. Call your doctor's office and ask what it costs to see the doctor for a sore throat. Watch the receptionist's face, even over the phone. The honest answer, in most offices, is "it depends on your plan, and we will find out after you come in." Nobody would buy a sandwich that way.

There is a corner of American medicine where the answer is a number, quoted up front, and it is usually the same number every month. It is called direct primary care, and in this playbook I will show you exactly how it works, how to find a practice, what to ask, and what it does not do. You can run the whole test in an afternoon, with a phone and a notepad.

One note before we start. This is a guide to a payment arrangement, not to treatment. Nothing here is medical advice, and nothing here is tax or legal advice for your particular situation. When it comes to your own health, your doctor decides. When it comes to your own taxes, a tax professional or the IRS decides.

Step 1: Understand what you are shopping for

Direct primary care, usually shortened to DPC, is an arrangement between a patient and a primary care practice. The patient pays a flat periodic fee, almost always monthly, and the practice provides a defined set of primary care services for that fee. No insurance company sits between the patient and the doctor for those services, so there are no claims, no copays at the visit and no billing department chasing codes.

The rest follows from that one design choice.

• A practice that does not bill insurers does not need the staff that handles billing, so the overhead falls.
• A practice that gets paid by membership instead of by the visit has no reason to hurry the visit.
• A practice with fewer patients on its roster than a typical insurance-based practice can usually offer same-day or next-day appointments and longer visits.

That is the pitch. Whether the pitch is true for any given practice is the question the rest of this guide helps you answer.

Step 2: Learn what a membership usually covers, and what it does not

Practices differ, so treat this list as a map of what to ask about, not a promise about what you will get.

What a membership commonly includes:

• Routine office visits, often without a per-visit charge.
• Annual physicals and preventive visits.
• Care for common, minor conditions that a primary care doctor treats.
• Some in-office procedures, such as basic lab draws or simple tests, depending on the practice.
• Direct access to the doctor by phone, text or email, with the rules for response time spelled out.

What a membership commonly does not include:

• Hospital care, emergency room visits and surgery.
• Specialist care, imaging and many lab tests that must be sent outside the practice, though some practices negotiate cash prices for these.
• Prescription drugs, though many practices dispense common ones at or near wholesale cost.
• Care for a serious, expensive illness.

This is the reason DPC is not a replacement for insurance. It is a way of paying for the routine part of health care directly, and I will say more about the other part in Step 7.

Step 3: Understand why it is not "insurance" under the law

You will hear a phrase in this field that sounds technical but matters: a DPC agreement is not an insurance contract. Many states have passed statutes that say so. The typical language defines a direct primary care agreement as a contract between a patient and a practice for a defined set of primary care services in return for a periodic fee, and declares that the arrangement is not insurance and is not subject to the state's insurance regulations.

Why would a state bother? Because without the clarification, a regulator might say a monthly fee for a bundle of future services looks like insurance, since it spreads a risk across members. Insurance companies in every state must meet capital requirements, file rates and follow a long list of rules. A small practice with a few hundred members cannot do that, and the law would have crushed the model. So the legislatures stepped in.

Two practical consequences follow.

1. The rules differ by state. Some statutes require that the agreement be in writing, that it describe the services and the fee, that it say plainly that it is not insurance, and that it describe how a patient can end it. Look up your own state's statute. Your state legislature's website will have it. Searching for "direct primary care" and your state's name usually leads there, and the Texas, Washington and Colorado statutes are examples you can look up.
2. The rules on the practice's side are a guide to what you should expect. If your state's law says the agreement must include a termination clause, you have every right to ask to see it before paying.

Step 4: Find practices near you

Now the shopping. There are four reliable ways to find a practice.

1. Search a directory. Trade groups and advocates for the model maintain maps and listings of practices by state and city. A search for "direct primary care directory" and your city or ZIP code will turn them up. Treat any directory as a starting list, not a guarantee, because practices open and close.
2. Search the practice's own site. Many practices have a page called "Membership" or "Pricing," and that page is the first thing to read. A practice that will not post its fee is telling you something.
3. Ask the independent doctors you already know. Some independent practices have converted to the model. A call to a current doctor to ask whether he or she offers a membership option, or knows a colleague who does, costs nothing.
4. Ask your employer's benefits office. Some employers contract with DPC practices as a benefit alongside the health plan. It is worth one email to find out.

Make a list of three practices. That is all you need for a fair comparison, and three is a short enough list to finish in an afternoon.

Step 5: Ask the right questions

Phone each practice, or use its contact form, and work through the questions below. Write the answers down. Where a practice answers vaguely, ask for the answer in writing.

On the fee

1. What is the monthly fee for one adult? For a child? For a couple? For a family?
2. Is there an enrollment or registration fee, and is it refundable?
3. Is there a minimum term, or can I leave at any time? What happens if I leave mid-month?
4. Can the fee change, and how much notice do you give?

On visits and access

1. How soon can I be seen for a same-day problem?
2. How long is a typical visit?
3. How can I reach the doctor between visits, and how quickly do you respond?
4. Who covers when the doctor is away?
5. How many members does each doctor have? A smaller number usually means more access, and a practice that tells you the number plainly is one that has thought about it.

On labs, drugs and referrals

1. Which tests and procedures are included in the fee, and which cost extra?
2. Do you offer cash prices for common labs and imaging, and can you tell me in advance what they would be?
3. Do you dispense common prescriptions, and at what price?
4. When I need a specialist, how do you help me find one, and do you have relationships that bring prices down?

On the limits

1. What does the membership not cover? Ask for the list in writing.
2. What happens if I have an emergency or need to go to the hospital? Does the practice coordinate with the hospital?
3. Do you accept insurance for anything? Many practices do not bill insurers at all, and that is how the model is designed.
4. If I am on Medicare, how does that work with a membership? This is a special case, and Medicare has its own rules, so ask this one directly and get the answer in writing.

A good practice will answer all seventeen questions in a few minutes. If it cannot, that is information.

Step 6: Compare the three, using a table

Back at your notepad, make a simple table with one row per practice and one column per item below. Here is the layout.

Then do the arithmetic. Multiply the monthly fee by twelve to get the yearly cost, and compare it to what your household actually spends on routine visits each year. The relevant figures are on your own explanation-of-benefits statements and receipts, which you already have. Here is an example, labeled as a hypothetical, with invented numbers for the sake of the arithmetic.

Hypothetical: Suppose a practice charges $80 a month for one adult. Twelve months at $80 is $960 a year. If that adult would otherwise have paid, in a year, four visits at $40 copay each, which is $160, plus $200 in routine labs, the membership costs more on paper. But if the same adult would have made six visits and paid a deductible of $1,500 before the plan paid anything, the picture may be different. The numbers are not the point. The method is: put your own numbers in, and let the arithmetic decide.

Step 7: Keep real insurance for the big risks

This step is the one that gets skipped, and skipping it is how a good idea turns into a bad bet.

Direct primary care pays for routine primary care. It does not pay for a hospital stay, a surgery, a cancer diagnosis or a car accident. Those events are what insurance exists for: a rare, very large cost that no household can predict. The sensible pairing, for many families who choose this model, is a membership for everyday care and a plan with a high deductible for the catastrophe.

Think of it the way you think of your car. You pay for oil changes and tires directly, because they are predictable and routine. You buy insurance for the crash. A family that uses a DPC practice for the oil change and keeps coverage for the crash is using each tool for the job it was designed to do.

This is also the pairing that the law has been moving toward. If you want to understand the health savings account side of the picture, read Eleven Questions About Health Savings Accounts, Answered for Working Families, which explains how the accounts work and who can open one.

Step 8: Check the tax treatment with the IRS, not with a salesperson

Here is the question families ask most, and the one where you should be most careful about whom you trust: can I pay a DPC fee from a health savings account?

The honest answer is that the rules have been in flux. For years, the IRS treated a monthly membership with a practice as raising problems for someone who wanted to contribute to an HSA, since an HSA requires that you not have certain other health coverage. Congress has since taken up the question in legislation, and the rules and dollar limits can change with each tax year.

So here is what I will tell you to do, and it is exact.

1. Go to the IRS website and look up Publication 969, which covers health savings accounts. Read the current edition.
2. Search the IRS site for "direct primary care" to find any current notice or guidance.
3. Check whether any limit applies to the monthly fee, and whether the fee counts as a qualified medical expense under the current rules.
4. If your situation is complicated, such as a self-employed filer, a family with a spouse on a different plan, or someone on Medicare, ask a tax professional. A practice's front-desk staff are not tax advisors, and neither am I.

Do this before you pay the first membership fee, not after. Tax rules reward those who read them in advance.

Step 9: Read the agreement, then decide

You have your numbers, your questions answered and your tax question resolved. Now do three more things.

1. Read the agreement from top to bottom. It should describe the services, the fee, the term, how to leave, and a statement that it is not insurance. If your state's statute requires specific language, check that it is there.
2. Ask one more question: what happens to my records if I leave? You are entitled to your records, and a good practice will explain how to get them.
3. Start small. Many practices let you begin month to month. Run a trial period, and judge by the standards you wrote down in Step 5, not by how pleasant the waiting room smells.

Why a conservative cares

Notice what is happening here. A patient, a doctor and a price meeting in the open, with a contract both can read, and no third party between them for the routine business. That is a small piece of what a free market in medicine looks like. It is also a small piece of what restoring ordinary prices to health care would mean, a subject covered in A Shopper's Playbook for Getting a Real Price Before a Medical Procedure and in Hospitals Went to Court to Keep Their Prices Secret, and They Lost.

The lesson generalizes beyond the doctor's office. Where a service is paid for directly and the price is posted, people shop, and where people shop, quality rises and prices behave. Where a third party pays and the price is hidden, nobody shops, and the bills grow in the dark. You do not have to take that on faith. You just ran an afternoon test.

The case in brief

1. Direct primary care is a flat monthly fee for a defined set of primary care services, with no insurer in the middle for the routine visit.
2. Many state statutes define these agreements as outside insurance regulation, so the rules vary by state and your own state's statute is the thing to read.
3. Find three practices, ask the same seventeen questions of each, and compare them in a table with the yearly cost worked out from your own numbers.
4. Keep insurance for hospital care and catastrophic cost; the membership is for routine care.
5. Check IRS Publication 969 and the current guidance before paying the fee from a health savings account.

What you can do: this week, find one direct primary care practice near you, read its posted membership terms, and write down its monthly fee and what it leaves out.