Starting a direct primary care practice means building a membership-based medical business where patients pay you a monthly fee (typically $50 to $150 per person) instead of billing insurance for every visit. The model has grown fast: the number of concierge and DPC practices in the U.S. jumped 83 percent between 2018 and 2023, reaching over 3,000. If you’re a primary care physician ready to leave the insurance treadmill, here’s what the process actually looks like from a legal, financial, and operational standpoint.
Understand the DPC Business Model First
In a traditional practice, a family physician manages panels of 1,200 to 1,900 patients and spends enormous time on coding, prior authorizations, and claim denials. A DPC practice flips that entirely. You charge each patient a flat monthly fee, typically between $50 and $100 for adults, and in return you offer unlimited or near-unlimited primary care visits, same-day or next-day appointments, and direct communication by phone or text. No claim forms, no insurance middlemen.
The tradeoff is a much smaller patient panel. Most DPC physicians carry 600 to 1,000 patients, which is what makes the longer appointments and same-day access possible. Your revenue ceiling is straightforward math: if you charge $75 per month and enroll 600 patients, that’s $540,000 in annual gross revenue. The simplicity is the appeal, but it also means you need to plan carefully because there’s no insurance reimbursement cushion if enrollment is slow.
Legal Structure and State Regulations
Nearly every state that has passed DPC legislation defines these agreements the same way: a direct primary care agreement is not health insurance. Virginia’s statute is a good example of the standard framework. It requires DPC practices to prominently disclose in all marketing materials and agreements that the membership is not insurance, that it covers only the specific primary care services listed in the agreement, that patients must pay separately for anything outside that scope, and that a DPC membership alone does not satisfy federal health coverage requirements.
You’ll also need to distribute a comprehensive disclosure statement to every patient at enrollment. This document must spell out their financial rights and responsibilities, encourage them to maintain insurance for services you don’t provide (hospitalizations, specialist care, imaging), and state clearly that you will not bill any health carrier for services covered under the agreement. These disclosure requirements aren’t optional add-ons. They’re the legal foundation that keeps your practice classified as a medical service rather than an unlicensed insurance product.
Check your own state’s specific DPC statute before you draft any patient agreements. Most states have enacted some version of this framework, but the details vary. You’ll want a healthcare attorney to review your membership contract, your disclosure documents, and your entity structure (most DPC practices operate as a PLLC or PC).
Opting Out of Medicare
If you plan to see any Medicare beneficiaries in your DPC practice, and most physicians do, you’ll need to formally opt out of the Medicare program. This is a specific legal process, not just a decision to stop submitting claims. You must file an Opt Out Affidavit with your local Medicare Administrative Contractor. Once approved, neither you nor your patients can submit claims to Medicare for services you provide.
The opt-out lasts two years and automatically renews unless you actively cancel it. During that period, you’re required to maintain a signed Private Contract with every Medicare beneficiary you treat. This contract confirms that the patient understands Medicare will not reimburse them for your services and that they’re paying you directly. Keep these contracts on file for the full two-year cycle. Failing to have them in order can create billing compliance problems.
Startup Costs and Financial Planning
The financial range for launching a DPC practice is wide, and it depends heavily on whether you’re leasing raw commercial space or moving into an existing medical office. At the lower end, expect initial capital expenses of $50,000 to $100,000, plus $40,000 to $75,000 in pre-opening operating costs before subscription revenue starts flowing in.
Here’s where the money goes:
- Leasehold improvements: $30,000 to $60,000, depending on how much work the space needs. A former medical office saves you tens of thousands compared to converting a retail storefront.
- Medical equipment: Exam tables, diagnostic tools, and basic lab equipment run around $15,000 for a lean setup.
- Furniture, signage, and IT infrastructure: Budget roughly $5,000.
- EMR and patient portal software: Initial licensing and setup for an electronic medical record system costs $5,000 to $10,000. A full membership management and patient enrollment portal can run considerably more.
- Malpractice insurance: Approximately $2,500 per month, though rates vary by state and specialty.
- Rent and utilities: A typical small clinic runs $8,500 to $10,000 per month including utilities and maintenance.
The critical financial reality of DPC is the ramp-up period. You’ll have fixed monthly costs from day one, but your membership base builds gradually. Most DPC physicians recommend having six to twelve months of operating expenses in reserve. That means enough cash to cover rent, staff, insurance, and your own salary while you grow from zero to a sustainable patient count.
Setting Your Membership Fees
Most DPC practices charge between $50 and $100 per month for adults. Family rates are common, with an upper threshold of around $300 per month for a household. Some practices use age-tiered pricing: lower fees for children and young adults, higher fees for patients over 65 who generally need more frequent care.
A major development on the insurance side takes effect January 1, 2026. Starting then, patients enrolled in high-deductible health plans can use Health Savings Account funds tax-free to pay DPC membership fees, and their DPC enrollment won’t disqualify them from contributing to an HSA. This is a significant change. Previously, IRS rules created friction for patients who wanted both an HSA and a DPC membership. Once this takes effect, you can market your practice as fully compatible with HSA-eligible health plans, which removes one of the biggest objections employers and individual patients have raised.
Choosing the Right Technology
Your EMR needs are fundamentally different from a traditional practice. You don’t need robust insurance billing modules, coding assistance, or claims management. What you do need is seamless membership management: the ability to enroll patients, process recurring monthly payments automatically, assign different fee tiers to different patient groups, and add one-time charges for labs or medications dispensed in-office.
Look for an EMR that includes integrated payment processing so patients can enter their own credit card information and pay bills through a portal. Direct communication tools matter too. DPC patients expect to reach you by secure message or text, so your system should support that without requiring a separate platform. Several EMR systems are built specifically for the DPC model, and they tend to be simpler and cheaper than the enterprise systems designed for insurance-based practices. Evaluate them based on how well they handle subscriptions and billing rather than clinical documentation features, which are fairly standard across platforms.
Staffing a DPC Practice
One of the biggest operational advantages of DPC is how lean you can run. Without insurance billing, you eliminate the need for coders, billers, and the administrative staff who chase prior authorizations and denied claims. A solo DPC physician with a panel of 600 patients can often operate with just one or two staff members: a medical assistant who handles clinical support and a front-office person who manages scheduling, enrollment, and patient communication. Some solo practitioners start with a single employee who does both.
As your panel grows toward 800 or 1,000 patients, you’ll likely need to add staff. A registered nurse can extend your capacity by handling triage calls, follow-up care, and chronic disease management check-ins. The key staffing principle in DPC is that every person you hire should directly improve patient access or experience, because that’s what your members are paying for.
Building Your Patient Panel
Enrollment is the make-or-break challenge for a new DPC practice. You’re asking people to pay a monthly fee for something they’ve been conditioned to access through insurance, so your marketing needs to clearly communicate what they get: longer visits, same-day access, direct communication with their physician, and transparent pricing with no surprise bills.
The most effective acquisition channels for DPC practices are local employer groups and word-of-mouth referrals from existing patients. Small and mid-size businesses that can’t afford traditional group health plans are natural partners. You can offer employers a DPC membership for their workforce, paired with a high-deductible catastrophic plan, at a total cost well below conventional insurance. With the 2026 HSA rule change, this pitch becomes even stronger.
For individual patients, your online presence matters. A clear website that explains your services, lists your fees, and allows online enrollment reduces friction. Community events, local networking, and partnerships with other healthcare providers (specialists, physical therapists, mental health practitioners) who can refer patients to you also build your base. Expect the first six to twelve months to be the slowest. Most DPC practices report hitting a sustainable patient count somewhere between month 12 and month 24.
Where DPC Is Growing Fastest
Geography matters if you’re choosing where to set up. As of 2023, Texas led the country with 402 concierge and DPC practices, followed by California (387), Florida (352), and Georgia (139). These states combine large populations, favorable regulatory environments, and high concentrations of self-employed individuals and small businesses, which are the demographics most drawn to DPC. But the model works in smaller markets too, particularly in areas underserved by traditional primary care where patients face long wait times and limited access.