Direct Primary Care vs. Traditional Primary Care

If you've been considering a DPC membership, this is a worthwhile read to help you decide if the expense is worth it.

UPDATED: July 7th, 2025

Welcome to the Healthy Aging Newsletter, a free publication that turns trustworthy medical research into simple habits so adults in their 30s and 40s can stay healthy and avoid common chronic conditions.

This isn’t an article to convince you of signing up with a direct primary care doctor. Well, first, a DPC is a family medicine or internal medicine doctor who left mainstream insurance-based work and opened their own physical or virtual practice. They charge a monthly membership for each patient and in return offer much longer appointment times, multiple visits, without the long waits. They charge you cash, so no insurance.

But this is an article to convince you that traditional primary care really falls short. In many large medical groups primary care is just a big funnel to feed patients into the healthcare system. The gatekeeper doctor is in charge of diagnosing diseases that can be treated by specialists — assuming the patient has decent health insurance.

It’s said that for every dollar paid to a primary care doctor, $6 can be made downstream from the patients they refer into that particular medical group or insurance network. That’s a 600% return on investment.

Traditional Primary Care is Broken

As a family doctor myself I was trained to order blood tests, perform exams on patients, and tell them what lifestyle choices to make to help them avoid chronic diseases. At least that’s what I was taught at UCLA. We discussed nutrition, exercise, medications, tests, everything.

But in the real world, when I work for a large medical group like Kaiser Permanente or Cleveland Clinic, I have maybe 10 minutes with the patient. I rarely can even address things like obesity because patients may feel judged or stigmatized if I mention their weight. I can order a few blood tests and then have my nurse call the patient back with the results once they are in.

The patient then comes back in 3-6 months, we start them usually on some medications, refer them to a few specialists and i see them again in 6-12 months. None of these visits allow enough time to really dive into nutrition, exercise, social bonds, sleep, rest, and recovery.

My job at these large medical groups is to keep doing screening tests until we find a disease early, assign it an ICD10 code, bill the insurance company for it, prescribe a medication that the PBM will profit from, and then send the patient to our own medical group’s lab, which we’ll also bill to the insurance company.

So far, everything is exactly as most Americans know it. It’s profitable, smooth, and functional — at least for the medical group. Not for the patient. The patient is just waiting for the next diagnosis to drop.

Healthy Patients Don’t Need Doctors - Until They Do

If you’re 30, healthy, active, and eat well, you’ll correctly assume that you won’t need a doctor. You’ll go on to your 40s and 50s and suddenly something goes wrong. Without having had much interaction with our US healthcare system you’ll do what you’re told especially when you end up in the ER for something scary. You will trust that the doctors have your best interest in mind.

In your 30s you’re healthy because you live in a country with a solid public health system. Water, air, sewers, climate, violence, vaccines, traffic, and our food supply have all been carefully thought out and optimized for the least negative effect for most Americans. It’s not perfect but there are few other countries where you can make it into your 50s without ever going to a doctor because we don’t worry about tuberculosis, stomach cancer, leprosy, congenital blindness, malaria, and Typhoid fever.

But because you live in the US you’ll likely have your body for another 40-50 years and that’s going to require a lot of preventative maintenance. It’s going to require you to know how the healthcare system works so that you don’t become a pawn or victim of it but instead can use it as a tool to keep you health.

Direct Primary Care Doctors Think Differently

Us DPC docs understand the weaknesses and strengths of our healthcare system. We know where there is a lot of hype and we know where you get the most bang for your buck. Back surgery and bunion fusion — not so much. Sepsis and autoimmune diseases — incredible value!

We don’t regurgitate pharmaceutical marketing material — aka, “research studies”. We have longer appointment times not because it takes a long time to prescribe a statin or send you for lab tests but because we know that you have to know how to prevent those diseases in the first place.

We believe primary care means that you should see us first without having to go to the ER or urgent care, unless your life is in imminent danger. A few pithy words exchanged will help us know exactly what to do for you. Most of the time, we can keep our patients out of the urgent care and ER.

We also keep our patients from unnecessary surgeries, prescriptions, lab tests, specialty referrals, or ineffective OTC treatments.

Traditional Primary Care is A Long List of Protocols

When you see patients for Kaiser Permanente, everything is a protocol. Your patient comes in with back pain, you give them a handout for exercises, some meloxicam, and you bring them back in 1 month. Not better? Referral to PT. Not better? Refer to ortho.

Every year your patients get a lipid panel and A1C, screening for high cholesterol and diabetes. If their LDL-C hits 101 from their last level of 99, it’s time for meds. You prescribe atorvastatin for 90 days, and a set of blood tests to make sure their liver is okay. Then the same for when their A1C goes from 5.8 to 6.5 — diabetes.

Protocols are nice because they keep costs low and everyone is treated in the same predictable manner. But that would be really tough if someone does fit the mold. As in, they don’t want back surgery or they don’t want meloxicam - then what? These systems don’t do well when the protocol has to be broken.

Direct Primary Care is Very Individualized

Obesity is not the same from one person to another. Neither is diabetes or menopause. We all experience health and illness in our own unique ways. As DPC docs we think this requires us to treat each patient uniquely. It takes a lot of conversations to figure that out but that’s why we have smaller patient panels.

Instead of a patient panel of 2,500-4,000, we have 300-600. It’s not hard for me to get to know 300 people. Admittedly, past this number and people blur a bit and I have to rely more on my EHR to remind me about their details. That’s why some DPC docs have smaller and others larger panels.

We don’t run the same blood tests on every patient. It’s rare to see a DPC doctor order annual CBCs, TSHs, or other common lab protocols because that leads to unnecessary false positives, useless data, and unnecessary costs to the patient.

We don’t refer everyone with a headache to a neurologist but we’ll probably refer more people to a nutritionist and physical therapist when they have headaches because we want to help them prevent future headaches. A specific diet and neck routine is quite effective and preventing many migraine and tension headache attacks.

Medication Prescribing is Very Profitable

If you’re a large medical group or health insurance company you likely have a PBM which drives a lot of your profits. In it, you have a steroid cream that would cost $8 if paid in cash for a tube but you mark it up to $128. Depending on the patient’s health insurance plan you will take that price up to $420 or as low as $12 for the same tube.

DPC doctors don’t prescribe a lot of medication. Of course I’m generalizing here. There are probably 2,000 DPC docs in the US as of this writing. Most don’t believe the mainstream system works but some may have a unique practice style. But most of us don’t believe that a statin or blood pressure medication is always necessary. We have the luxury of time to sit down with you and discuss the pros and cons and use proper risk calculators to assess your cardiovascular risk.

Unnecessary Tests Are Expensive

Large medical groups are risk averse, meaning they don’t like to take on unnecessary risk of getting sued by patients, so they’ll do a little more, just in case. If you come in with a headache for the very first time, you’ll probably get head imaging. Slightly high blood pressure, blood pressure meds. Even borderline high cholesterol, statins. Back pain that’s not better after 4 weeks, MRI.

You might be reading this and saying “Nice! Bring it on, that’s how I want my doctor to be!” And there is a lot to be said about the scary stories we read when patients have had major cancers or other diseases missed by their doctors. But that’s a nuanced conversation.

We 4x as many cancers in the US as less developed countries do. And our mortality rate is only slightly lower. We are clearly overdiagnosing and overtreating cancers. We are getting way more MRIs and CTs and our patients aren’t having less back problems or better back pain outcomes than comparable nations.

DPC doctors take a more nuanced approach. An MRI can be done for <$500, cash. The patient gets the order when they see us so they don’t feel that we’re holding out on them. But then we have a deep discussion about the risk of getting that MRI and having it show a suspicious lesion or disc herniation — likely just false positives which still will lead to a lot of anxiety and unnecessary chemo, surgery, etc.

We order tests when we believe they are actionable. When we believe that the outcome of this test would significantly change the course of action for the patient.

The Major Downside to DPC Doctors

Health is the balance of illness and healing. The body gets sick and then repairs itself. The role we play as participants in this homeostasis is to make small daily decisions that help the body’s ability to heal, fight off infection, curb inflammation, and repair oxidative stress. So the hard work is those small, daily choices and actions that the patient has to actually do.

In mainstream medicine you go in for tests, things are discovered about you, treatments are done to you, and more tests are done to see how the treatments are doing. In DPC you are empowered with the responsibility of taking care of your body and you report to your doctor how things are going and that doctor will help you through the many choices.

There is something streamlined and simple about being told that you have prediabetes and high cholesterol; here is your atorvastatin and metformin, off you go. It’s predictible and you can look it up online, you’ll be reassured. When you talk to your gym buddy, she got the same diagnosis, the same meds. There is solidarity there.

In a DPC practice, high cholesterol or blood glucose readings are a health crisis and action has to be taken. It’s a “your hair is on fire” situation. Work schedules have to be changed, grocery store shopping modified, social events moved around, time carved out for a different eating and exercise routine. It’s messy, disruptive, and unique to you.

And the promise is that if you do all of this right and don’t lose the daily genetic dice roll, then there is at best a really good chance, but no guarantee, that you’ll prevent these chronic conditions. Understandably, for some, this is not all that enticing.

The Income For Doctors is About The Same

Do the math — $100 per patient per month and a patient panel of 500. Nice, that’s $50,000 per month! DPC doctors are earning $600K a year? Of course they would rather do DPC, that’s double what they would make working for a large medical group as employees.

Employed family medicine doctors in primary care earn around $275K a year and they’ll have a hefty tax bill to pay for this, of course. They will work around 50 hours a week and see 18-30 patients per day, 5 days a week.

Most DPC doctors will have a panel of 300-500 but there is a lot of turnover. The average patient sticks around for 2 years before they move or can no longer afford the monthly membership fee. We also give a lot of discounts to those who can afford it. And we have staff, even if we have virtual DPC practices. The average DPC doctor pays themselves a salary of around $150K a year, sometimes $200K — and they’ll pay taxes on this, too.

So, the salaries are the same or maybe a little less for most DPC doctors. But we get to practice the way we think is best for patients. And we rarely work more than 40 hours a week and have around 8-10 patients per day.

The Final Verdict

At $100 per month — the average DPC membership fee — you’d pay $48,000 over your lifetime. The advantage is that you’ll have the same doctor for those 40 years and you’ll rarely wait for an appointment. Your doctor is a text, phone, or quick drive away from you at all times. If you move, change jobs, lose jobs, lose your health insurance - you’ll likely always be able to keep your DPC.

That DPC doc will save you many, many unnecessary diagnoses, treatments, referrals, ER visits, prescriptions, and headaches. The question is, what’s the value of that? Because they’ll also hold you responsible for your own health. Which means they’ll want you to take care of your health. In return, they’ll save you from lifelong diabetes, cancer, stroke, heart attacks, and arthritis.

So there is potential health savings and cost savings but it comes at the cost of having to do a lot of heavy lifting.

It’s also possible you’ll find that one primary care doctor in your insurance network who is the diamond in the rough. They care, listen, and don’t mind running late to your appointment because they spend listening to the patient right before you.