It may not be possible to remove insurers entirely from U.S. healthcare, but physicians curious about how to limit their interactions, including residents and fellows in the transition to practice, should investigate direct primary care as an alternative practice model.
Though direct primary care may often be conflated with concierge medicine—itself sometimes called “boutique medicine,” “retainer medicine” or “retainer-based medicine”—many healthcare organizations and physician practices define them separately.
Typically, direct primary care practices do not accept health insurance and will not bill to health insurers, instead charging a monthly fee that often ranges from $20 to $50 for children and $50 to $100 for adults, according to 2024 data from the American Academy of Family Physicians. The monthly charge covers primary care that sometimes also includes labs or x-rays.
Prevalence of practice model unclear
Lindsey E. Carlasare, a senior manager for research and policy at the AMA, said that in part because direct care practices do not always accept insurance, which would require the practice to be registered with a health insurance database or a state or specialty regulatory body, it can be difficult to get official numbers on exactly how many exist.
“The model still is relatively uncommon,” she noted.
There are some indications, however. DPC Frontier is a direct primary care legal and policy research website founded by a physician advocate for direct primary care. According to the site’s 2026 figures, there are more than 3,000 direct primary care practices in the U.S., which are divided into three types:
- Pure, which take no insurance whatsoever.
- Hybrid, ones in which insurance is billed in addition to an out-of-pocket monthly fee.
- On-site practices, which typically exclusively serve the employees of a large corporation.
Read more here about what it’s like to practice as a direct primary care physician.
Weigh factors for direct primary care
While the experiences of individual physicians vary, some of the potential benefits include:
- Fewer time restrictions with patients.
- More professional satisfaction.
- Less interaction with insurers.
- Better work-life balance.
- Smaller patient panel.
The potential drawbacks for physicians practicing in direct primary care can include:
- Possible lower income at start.
- Risk of feeling isolated.
- Fewer patients.
- Need to recruit and build patient base.
- Complications related to operating outside of traditional payment models.
For those who have selected direct primary care as their preferred practice model, the AMA Code of Medical Ethics lays out guidance so that physicians can offer their patients transparent, fair retainer agreements for direct or concierge primary care.
IRS clarifies HSA fund use
Carlasare said one of the key criticisms commonly levied at direct care is that some patients may not be able to afford even a modest regular fee.
“Some people say it limits access to care,” she said. “Some doctors don't want to deal with insurance and they only want to deal with patients on a fee-based service, but many people with Medicare or Medicaid can't afford that [monthly fees] if they need to use their benefits to get care.”
Physicians in direct primary care, however, argue that the transparent pricing allows patients to budget for their primary care. And starting in January, new guidance from the IRS took effect saying that patients now can use health savings account (HSA) funds to pay direct primary care charges as long as the fees are less than $150 a month per individual or $300 a month per family. The funds must be used for primary care services provided by a primary care physician or other allowed health professional. The AMA has policy supporting the inclusion of direct primary care as a qualified medical expense by the IRS.
Carlasare said that though there are physicians and patients who are passionate about direct care, it is not a model that appeals to everyone. And it does not remove all bureaucratic burden from the physician.
Those practicing in direct primary care, she noted, “have to start a practice, and that's a lot of a lot of work ... You still need to have all the things that a practice would need to have.”
Learn more with the AMA STEPS Forward® “Physician Payments Model Guide,” which helps physicians understand the rapidly changing payment landscape. The AMA has designated this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Learn more about the AMA’s CME accreditation.
