From the days that Philip Eskew, DO, was in his first year of medical school, he knew he wanted to be in direct primary care. Both of his parents are physicians—his mother a pathologist and his father a family physician—and he said their experiences, both positive and negative, inspired his career path.
“They enjoyed medicine but not the ancillary administrative tasks that had increased over the years,” said Dr. Eskew, an AMA member who also has earned a law degree and a master’s degree in business. “I approached medicine with that in mind and wanted to be able to do something about the aspects of it that had frustrated them.”
He saw direct primary care—a model that aims to scale back the role of health insurers and other third-party payers in the patient-physician relationship—as a promising way to do that.
Dr. Eskew now serves as vice president and general counsel with a South Carolina-based practice with locations in more than 20 states and provides direct primary care to patients from large employers throughout the country. Dr. Eskew estimates he spends about 65% of his time providing patient care every week. He is also an advocate for direct primary care and took time recently to explain what he wished he’d known about the payment model when he was a resident physician.
An emerging practice model
Though direct primary care (DPC) is often conflated with concierge medicine—itself sometimes called “boutique medicine,” “retainer medicine” or “retainer-based medicine”—many health care 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.
Concierge medicine practices, on the other hand, often charge annual, quarterly or monthly membership fees from a few thousand dollars to $10,000 and up, also billing covered treatments and services to a patient’s health insurance plan. Some concierge medicine practices charge $40,000 or more per year in membership fees. Additionally, concierge medicine is not limited to primary care.
Dr. Eskew founded DPC Frontier, a direct primary care legal and policy research website, 12 years ago to advocate the practice model and share his insights with other physicians. According to the site’s 2026 figures, there are nearly 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.
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.
The upside of direct primary care
Dr. Eskew said physicians in direct primary care “get to provide ‘broad scope’ care beyond what the average family medicine practice” can offer. Other key benefits he has found include price transparency and patient autonomy.
“Patients are always in control over their own care,” he said. “Education can be emphasized because we have the time to do these things and benefit from an ongoing and consistent clinical relationship.”
He added that in his practice, technology isn’t forced by a third party. It can be adopted rapidly when helpful and just as quickly discarded if it becomes inefficient.
Doctors working in a direct primary care model, he argued, “do not burn out on administrative tasks and get to focus most of their energy on actual patient care.” Dr. Eskew appreciates that patients drawn to this care model can pick their practice and “tend to be more motivated or activated than the average patient and often have more unaddressed or undiagnosed chronic conditions.”
He said that “there is a greater sense of making a difference on a regular basis.”
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.
Some downsides to direct primary care
Though Dr. Eskew said direct primary care offers physicians many benefits, its relative rarity can require educating patients on how best to use the practice model, something he said can thrust small or new practices into a “sales” role that may be unfamiliar territory.
He also said it does not completely eliminate bureaucratic frustrations.
“We still have some unavoidable third-party headaches. We encounter some prior authorizations even though we don't ‘take insurance,’” he said, adding that direct primary care practices also may have trouble determining the out-of-pocket costs for their patients to see specialists for certain procedures or visits.
While the direct-care model is sometimes criticized for creating a tier of medical care inaccessible to those who cannot afford to pay out of pocket, Dr. Eskew argued that DPC “increases access to care.”
He said patients can bring all their health concerns to their direct-care primary care physician, who likely will not be as limited by the amount of time they are able to spend in each appointment. Patients also may be able to forestall expensive emergency department visits with timely preventive care.
Additionally, Dr. Eskew said physicians experiencing burnout or seeking to reduce their patient load can do so while still maintaining their practice.
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.
An evolving landscape
Much remains to be seen, Dr. Eskew noted, as the direct primary care model expands and is adopted by physicians in different specialties emphasizing price transparency in their practices.
“I wish more physicians knew about this model while contemplating their training and approach to care,” he said.
