Rebekah Bernard, M.D. 0:00
What's the average price point for a direct primary care membership? How many patients do you need to have a full panel? And how many physicians are actually running a micro practice, working completely solo with no staff at all? A new nationwide survey of 465 direct primary care physicians has the answers, and some of them may surprise you. Today, we're joined by the physicians who designed and led the largest survey of its kind to discuss what they learned, why these findings matter, and how they're helping the next generation of physicians build sustainable, independent direct care practices. Hi,

Speaker 1 0:57
I'm Dr. Kenneth Q. I'm a family medicine physician. I started my direct primary care straight out of residency, coming up on five years now in Richmond, Virginia, and I was chair of the member insight committee that put this report together.

Speaker 2 1:11
I'm Dr. Emily O'Rourke. I started my DPC micropractice, Fountain Direct Primary Care, in Chesapeake, Virginia, in 2018, and I was also a member of the committee.

Speaker 3 1:23
I'm Dr. Kelsey Smith. I started my direct primary care practice five years ago in Stillwater, Oklahoma, after having been in insurance-based care for 14 years.

Rebekah Bernard, M.D. 1:32
In 2024, the Direct Primary Care Alliance (DPCA) commissioned a survey of direct primary care practices across the country, led by Dr. Kenneth Q.

Speaker 1 1:46
Inside the community, there's a lot of us that talk about what the panel size or price should be, and there's never really been a survey or any sort of objective data to back those up. This was just a way to try and capture exactly if what we're saying by word of mouth actually matches up with reality, and so it was really cool to put this together and put numbers and real life data to some of the stories we tell each other.

Rebekah Bernard, M.D. 2:15
Kenny, can you explain the process of developing and creating a survey and all the effort that went into this.

Speaker 1 2:22
First, we had to craft the questions, and we wanted to make sure that a lot of people filled it out. So the first kind of directive was to make it short, so it wasn't like a 1015 minute survey nobody would do. We came together as a committee, came up with some questions. We had Dr. Rebecca Etz at VCU, the Larry Green Center, help us look it over and make sure it was legit. Then the board looked it over once it was ready. That's when we were kind of off to the races. So we sent it through the Facebook group, through email, through any network, anything that touched DPC. I'm still amazed at just how the community came together to do this, and then I had Dr. Allison Huffstetler as well as her postdoc help us go through the data, do statistical analysis, and come out with some great numbers and insights.

Rebekah Bernard, M.D. 3:12
Here's DPCA President Dr. Kelsey Smith.

Speaker 3 3:16
We received 465 responses, and obviously that's not all DPCs. We have many more DPCs than that, but that's a lot more than similar studies have been able to garner that have attempted this. And I think part of that is because of the study design, making it a digestible, meaningful survey improved our ability to get responses from people that were interested in participating. We got participants that were alliance members. We had participants that were non-alliance members. We had practices that were from across the map and represented anything from multi-position practices to micro practices. I feel like we had a very good representative sample to draw our conclusions from.

Rebekah Bernard, M.D. 4:03
survey received 465 responses, representing about 13% of the estimated 3,600 total number of DPC practices across the country. The states with the most respondents were Texas and Florida, with a dominance among states without Medicaid expansion, here's Dr. Q.

Speaker 1 4:26
This was something that I had assumed even before the survey went out. Like you know, it feels like the states that didn't expand Medicaid have a lot of DPC, and sure enough, here we are. It's definitely a contributor, right? Because right now, for the states that did, we're finding Medicaid is running out of money. You have the subsidies going away, and a lot more people are switching to health shares, going uninsured, and all that. But the states that kind of catalyzed this push were the ones that didn't expand Medicaid, and so DPC was really a safety net for this group. One

Rebekah Bernard, M.D. 4:57
of the biggest surprises was the perception. Of women who answered the survey, making up 67% of respondents. Here's Dr. Smith. The

Speaker 3 5:08
advantages that direct primary care offers are more appealing, perhaps, to a female physician and the demands that are placed on our time and attention, and just desire in how we want to structure our practice, and so not that that can't be true across the board, but I think that there are certain aspects of direct primary care that preferentially appeal to the female physician.

Rebekah Bernard, M.D. 5:31
And I think, especially in light of the fact that we are seeing more women leaving medicine at a younger age compared to men, hopefully this shows that direct care, whether it's primary care or perhaps in a specialty care, it could be a viable option for those women rather than leaving medicine entirely. Most respondents were family physicians, and 11% were internal medicine physicians, and 6.4% pediatricians. 76% of respondents were M.D.s, and 24% D.O.s, which is disproportionately higher than the overall percent of DOs in practice. Here's Dr. Smith on why she thinks DOs may be attracted to DPC.

Speaker 3 6:12
I am an MD, but my previous partners in insurance-based care were osteopaths, and the pressures of an insurance-based practice really caused them to lead leave a lot of their osteopathic skills behind because manipulation and osteopathic care does not fit nicely into the constraints of a 15-minute visit. So a lot of times they would not practice the skills that they were taught simply because of time constraints, I can only imagine that a lot of the osteopaths who have come to direct primary care feel a little bit of independence in being able to incorporate those skills back into their daily schedule because of the reduced time constraints that direct primary care allows, and it also allows you to put your price point where that can be adequately reimbursed, the

Rebekah Bernard, M.D. 7:03
average age of respondents was 46 years old, with ranges of DPC practice owners from 29 to 73. Here's Dr. Q.

Speaker 1 7:14
If you look at 40, there's like a big peak. I call that the peak of despair, right? You usually graduate 2930 if you went straight through or took a year off, and you've worked in the system. You mostly pay down your loans. You're kind of mad at everything, and then you start a DPC. Right, that is the age where you just exit. You're like, I'm good. I'm I'm going to go do my thing now. And so to the point about like starting from residency. So this survey was done in 2024. I started my practice in 21. When I started out, I was kind of a unicorn. I would say that percentage was significantly less. I wouldn't be surprised if it was sub five. But now I'm running into a ton of people who are starting their practices straight out of residency. And in fact, there's this like new playbook that emerged over the last several years where people are starting their practice is third year of residency, so it ramps up, and by the time they graduate, they have enough of a panel to kind of sustain themselves without having to work full time at urgent care or somewhere else, like a lot of us did when we started straight out of residency. One

Rebekah Bernard, M.D. 8:13
of the biggest surprises of the survey was the average full patient panel size. It's often quoted in DPC that a typical full panel is 600 patients, and while the survey answers did cluster in the 400 to 700 range, a sizeable number of respondents indicated that they had a full panel with far fewer patients, with ranges from 100 to 300. Dr. O'Rourke is one of those physicians.

Speaker 2 8:43
Yeah, so this was fascinating to me because I thought that I was out here this one unicorn that decided to stay micro. But in actuality, I think many practices decide to do this. My initial plan was I'll start out micro and then add staff as I need them. But once I saw all of the advantages of the micro practice and how much leaner it is financially, and I wouldn't have to do the human resource and management piece, it just made a lot of sense to me. And when you look at the data, it looks like you have this collection of practices that has the four to 700 patients with staff member, and then you have this other group of practices that are micro practices in that 100 to 300 range.

Speaker 1 9:31
Yeah, I had heard all the talking points, just like you you guys have, right? But as I talked to more and more DPCs, I heard more and more ranges. There are some people as low as like 200, 100, it's like their side gig, or maybe they were considering retiring, but they still want to practice some medicine all the way up to the go getters who are like you know above 800. It's cool seeing what full means and whether this is their like main thing that they do with their entire life, or if it's just the side thing and how. Efficiently, they do it right, keeping it anywhere as little as under 50 all the way to over 1000, which I still don't understand. But somebody's doing it somewhere.

Speaker 3 10:10
When I started the PC, and somebody would have asked me what my target panel size was, I mean, I was I was naive. I was like, "Well, I'm being an insurance based care. My panel was between 20 503,000. Surely, I can take care of 1000 people. No problem. That's a significant reduction in workload, right? But then you realize how much greater the interaction is with your patients in the direct primary care model. And I very quickly decided 1000 was a little bit of an overshoot in my mind. But at the same time, as an entrepreneur, like you said, Emily, there's there's these stair steps, and we see it in a response that you reach a point where you're like, okay, I'm pretty happy at this level. Do I make the decision to grow as a business and take on that added expense, and then have to basically make up for that increase

Speaker 2 11:00
in cost by increasing your panel size. So I think that just shows a lot of different doctors answer that challenge differently. To me, a full panel means that you're happy with both your work life balance and with your income, and that actually encompasses quite a large range. In the same way that when you're eating full is a large range. Like full might mean like oh I'm satiated I'm good, but I could you know still save room for dessert versus like I'm Thanksgiving Day full I can't eat another bite I'm just bursting and so you can have this range of full where if you get below that number, you're not surviving financially unless you have a side gig. Versus if you're at the top end of your full range, where you're going to either need to close your panel or hire staff. And so I think there is a wide range where people are saying, "Well, yeah, I'm full, even though I haven't closed my panel.

Rebekah Bernard, M.D. 12:01
Moving into staffing, most of our respondents had a single physician, single location practice. Most DPC practices that responded did not have a nurse practitioner or physician assistant working with them. And then I was very surprised looking at the question regarding number of staff that over 30% of our respondents are running a micro practice, meaning they have no staff at all. The most common answer at about 35% is having one staff member, and then 20% of people have two staff members, and so on.

Speaker 1 12:38
I'm curious to hear from Emily on this one.

Speaker 2 12:40
I came to the conclusion that all of the things that a staff member could do for me, I could either hire that out, such as paying a social media marketing company to handle that for me and take that off my plate without them being staff, or I could do it myself with fairly minimal effort. So it just didn't make a whole lot of sense to, for example, hire a nurse to bring the patient back, take the vitals, ask them some questions, only to pass it on to me to have me kind of ask the same questions, have the same conversation with them, maybe even recheck their vitals, and then what? Bring the nurse back in to do education. All of that was really kind of a feature of you know the seven minute visit that you have in the system. You have to do that to you know keep the assembly line moving. But if you're actually taking time with people and you're taking a full history and doing a complete exam, having that other role doesn't make a whole lot of sense. On the other

Rebekah Bernard, M.D. 13:45
hand, you've got the people that really want to have that right hand person, so that either they can see more patients or not be at the office as much. That's I'm one of those, Kelsey. I think you're one of those too. I am.

Speaker 3 13:56
Yeah. If my right hand left me, I think I might have to retire. We've been together 19 years.

Rebekah Bernard, M.D. 14:00
I say this every day.

Speaker 4 14:04
Yeah, I

Speaker 3 14:05
think it points out something there that you know direct primary care. I think even people who are looking at a micro practice, Emily, and correct me if I'm wrong, but there may be some barriers to entry there in thinking, well, I don't know how to do that. How do I room a patient? I've never had to do that before. How do I draw a lab if I want to open the door? Right? Do you feel like that was a barrier to entry in starting your own micro practice, as far as being the one that answers the phone, being the one that handles your books, being the one that brings the patient back, things like that? It seems like that's becoming less and less a barrier to entry as doctors see it being done across the board, and the same thing, it's a huge shock to patients. I mean, I have staff, but I'll still occasionally get to the phone, and people are shocked when they're like, "I must have called the wrong number. I'm so sorry, Doctor Smith. And I'm like, "No, I occasionally answer the phone. It's okay. In general, I don't answer the phone. You know, I let things go to voicemail. I let patients know that I prefer text, and I mean most people nowadays prefer text anyway. So most of the phone calls that I'm getting are are spam and people trying to sell me something or whatever. So I'm just letting everything go to voicemail, and then I'll return any calls that need to be returned. That's one way of just showing folks that you can can set your own expectations for your patient panel and design your practice around the way that works best for you. I love that. I

Rebekah Bernard, M.D. 15:30
want to make sure we get into pricing because it was one of those huge surprises. Because for the last decade, we've been throwing around the average price point of $77 a month for GPC practice that is based on data that came out in I believe 2014, and this survey found something quite different. It actually discovered that the overall average price across the country from our respondents was $98.46 per month. Did that surprise any of you?

Speaker 2 16:02
It was very shocking to me because the the mythological price that I had that was passed around when I was first investigating DPC was that $50 per month was like the appropriate and the only price that that you should charge, and if you charge more than that, you were an evil business person.

Speaker 1 16:20
That drum's still getting beat.

Speaker 2 16:22
Yeah, interestingly, I've raised my prices from 75 to 100 at this point, and I actually figured it-that's the exact rate of inflation from 2018 until now. So I just happened to raise my prices along with inflation, but I kept patients grandfathered in, so my average per member per month is at 82, which actually puts me below that average.

Rebekah Bernard, M.D. 16:49
I think a lot of us did have to raise prices around the COVID era because we certainly saw some rising prices in wages if we have staff, and then certainly in supplies. But what's so interesting also about this survey is that you can definitely see some price differences depending on where these practices were located. So first of all, lowest price across the Midwest at about $80 a month, and then highest price out in the West, $113, closely followed by the Northeast at $110, I would say those are areas that have higher costs of living compared to the Midwest. We also saw significantly lower prices in rural areas, $81.56 on average, compared to urban practices at about $110. So I think also speaking to the cost of living and perhaps the expectations of patients, and then finally, when we broke down the pricing by the practice patient panel, we saw that smaller practices of under 200 had a higher price point, almost $106 a month, and patients with a higher patient panel over 500 were priced the lowest at about $78 a month.

Speaker 2 18:04
That makes sense. If you have half the panel size, you're going to have to charge double the price to bring in the same profit.

Speaker 1 18:10
I think that there's definitely some context to this, which takes some understanding of the community. The thing that I think contributes to this is I mentioned the Generation One pioneers in the middle of the country, their practices were, I would say, anywhere between five and 10 years old. And doctors have this like thing where we don't like to raise prices or like make money. And sometimes when we're our own bosses, and you see this all the time in the Facebook groups, right? People make such a big deal. They're like, I finally did it! I raised my prices. Everyone's like, "Yay! Right? If it was a normal thing, it wouldn't be such a big celebration every time. And so you see the probably the older practices that happen to be in rural middle America with larger panels be lower because they probably set a price at some point and either marginally or haven't raised their prices since they started five to 10 years ago. That's my best estimate as to like why these numbers kind of pan out the way they do.

Rebekah Bernard, M.D. 19:08
Well, you know, Kenny, what you're saying is so interesting because we also broke it down by the age of the practice and the price, and what you can see is that practices that have been around for more than 10 years, actually had the highest price point, and I'm wondering if that reflects people maybe like me who now I'm at 10 years and I'm like prices going up for anybody new that's coming in because I'm not trying to grow, I'm just trying to remain the same. Then you have those people that are maybe what you're talking about. They've been around for a while, they're established five to 10 years. They had the lowest price point at about $86 a month, and then you have the newer people that are pricing a little higher, around $110. I think in some cases because they're realizing that those low prices just aren't really sustainable, especially in today's market.

Speaker 1 19:59
Yeah. And the move to suburban and urban markets, I think, is a newer one, or at least the return to urban markets.

Rebekah Bernard, M.D. 20:06
That's a good point, Kelsey. Did this pricing surprise you at all?

Speaker 3 20:10
It didn't. It kind of reflects, I think, what we have seen colloquially in the in the social media groups and things, as far as people feeling a pressure to increase their prices to account for greater cost expenditures and things like that, as inflation hits and the markets change and things like that. The only other paragraph we didn't touch on was on the tiering of pricing. I know I personally started just because that was kind of the accepted norm was to have pricing based on age tiers, and by the time I've made it to about my fourth year in practice, I realized that utilization was not adequately projected by age, and so I I changed my pricing to a flat fee for adults 18 and above, and another for children. I think we're seeing that no tiering has increased to about 15% of our respondents.

Rebekah Bernard, M.D. 21:02
Yeah, just to summarize what the survey found, 76.4% of practices reported having a tier, and then no tiering, 15% and then some people did family tiering. I also started with tiering just because that's what everybody was doing at the time when I started my practice, and I do agree with you, Kelsey. I think fewer tiers. I still have two now. I have an adult price and then a Medicare price. That's a little bit more, but I think flat pricing, if I was going back in time, might have been the way to go.

Speaker 1 21:31
We transitioned from age tiering over to family tiering. I think around the time of this survey, so I probably filled out family, and the rationale for me was that I wanted to incentivize, especially big families, to come in because they're the ones that go to the games, talk to other people in their neighborhood, and you know, word of mouth. And one thing that I've noticed when you have families, either only the kids come in or only the adults come in. It's never like the whole family needs everything all the time, and so based on all of that, I wanted to incentivize more families to come in as a unit. And sure enough, when we made the transition, there were a bunch of people who started signing up their kids and their spouses. Most of our patients, their entire families, see us because of this, or at least in part.

Rebekah Bernard, M.D. 22:18
So, do you have an individual price and a family price.

Speaker 1 22:21
So yeah, basically the monthly membership decreases per added person. So it doesn't matter what the age is, as long as you kind of live together. We're pretty loose with the rules. If you pay together and you like roughly seem related, we're cool with it.

Rebekah Bernard, M.D. 22:36
You're collecting from one person, so that simplifies matters too. I think that's a really good idea. I think that's something that, if I was starting over, I would definitely want to do that.

Speaker 3 22:45
We've said for ages that if you've seen one DPC, you've seen one DPC. But I think this data supports that even further. That you can make it what you want and need it to be to be successful. What I find encouraging is being able to publicize this to docs that are made at DPC curious, and just to see that there is a wide range of pricing that is sustainable in DPC. It really does come down to what is your environment, who is your target population, what is your expectation as far as what you want your panel size to be? What do you anticipate your monthly expenses to be? So I find that highly encouraging, and I'm ecstatic to be able to share some of that data with people who have a lot of questions about how they make the jump into DPC. I'm like, it is not a one size fits all model.

Rebekah Bernard, M.D. 23:39
Yeah, I think this survey shows again to your point. You should not compare your practice to someone else's practice or even the average, because as you can see from this survey, there is really all across the board a different range of doing direct primary care successfully. So instead of asking how many patients should I have, how much should I charge, we should be asking ourselves what kind of practice do we want to build, what kind of life do we want to live, and how can we do this sustainably and keep it going over time?

Speaker 3 24:11
Right. How do you be an architect of your practice with that in mind?

Rebekah Bernard, M.D. 24:14
While the survey was produced by the DPCA, Dr. Smith notes that it was created for all physicians,

Speaker 3 24:21
regardless of whether you're a member of the alliance or not, the alliance is very grateful to everyone that took the time to participate. This report doesn't belong to just the alliance; it belongs to the community at large to help forward the work that we're all doing. And we hope that the physicians who read this report can make better decisions moving forward and continue to advance the movement.

Rebekah Bernard, M.D. 24:43
If you'd like to read the entire survey, visit the Direct Primary Care Alliance website. The survey will also be published in an upcoming edition of the Journal of the American Board of Family Practice. Thanks so much for listening to this episode of Physician. Taking Back Medicine, a podcast sponsored by Medical Economics. I'm your host, Dr. Rebecca Bernard, bringing you true stories of day-to-day physicians just like you who are fighting to improve the healthcare system. Thanks again, and we'll see you on the next episode.

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