Let’s make ‘direct primary care’ a household term, DPC docs say

Direct primary care's biggest advantage is what it lacks: rules imposed by insurance companies, said three physicians who've taken different paths into the model.

This month, Primary Care for America held PrimaryCare26: See the Possibilities, a daylong conference in person and online for experts to share their insights about the latest developments in primary care, including direct primary care. Panel discussion included Kelsey Smith, M.D., a family physician in Oklahoma, and president of the Direct Primary Care Alliance; Michael Hobbs, M.D., a direct primary care pediatrician and founder and owner of Lakes Pediatrics in Minnesota; and Sabina Singh, M.D., a family practitioner and co-founder and chief medical officer of Anovia Health, an employer-based direct primary care practice in Wisconsin. They spoke during a conversation moderated by Sara Pastoor, M.D., M.H.A., head of primary care advancement of Elation Health, who also practices direct primary care in San Antonio, Texas.

Their conversation covered how direct primary care is playing out differently in pediatrics and employer-sponsored practice, survey findings on the movement's growth nationwide, how each of them is using artificial intelligence day to day, and the barriers and policy changes they'd like to see over the next five years.

"DPC started as sort of this fringe, grassroots movement, and now has taken the country by storm and is becoming more and more popular," Pastoor said, adding that adoption rates have been doubling or tripling year over year among both physicians and patients.

DPC in pediatrics

Pediatrics presents “kind of a catch-22” for direct primary care, Hobbs said. Between 40% and 50% of children are covered by Medicaid at any given time, and roughly three in five will be on Medicaid at some point before turning 18, meaning most children already have good coverage for preventive care, including vaccines, through traditional insurance. A second catch-22, he said, is that the benefits of pediatric intervention often aren't visible until a patient reaches adulthood, making the near-term return on investment harder for policymakers to see.

Because direct primary care practices don't bill insurance, they typically don't have a built-in way to cover vaccines, Hobbs said, which forces pediatric practices to find a separate vaccine source or strike a deal with a third party, something he called the biggest friction point in the field. A provision in last year's federal tax law that allows health savings account (HSA) dollars to pay for direct primary care doesn't solve that problem for families without existing insurance coverage, he added.

Pastoor introduced the topic by describing her own family's experience: her youngest child began seeing a direct primary care doctor as a teenager and developed a direct texting relationship with the physician, without needing a parent to arrange every appointment. That kind of relationship, Pastoor said, is something her daughter now considers normal, even though it would have been unusual in a traditional practice.

An employer-based model

Anovia Health has grown from zero to about 17 near-site and employer clinics serving roughly 40,000 patients in five years, Singh said. “So you're right, it has been tremendous growth,” she told Pastoor.

The practice built its case with employers by keeping the offering simple and identifying what employers actually wanted. They want healthier employees and a benefit that's easy to explain, particularly in Wisconsin, where consolidated, expensive hospital systems dominate the market, she said. Anovia works directly with insurance brokers and third-party administrators to help employers figure out how the arrangement fits into their existing benefits, Singh said, and now counts manufacturers, banks, school systems and county governments among its clients. What keeps employees engaged, she said, isn't Anovia itself so much as the personal relationship and unhurried time with a physician, which builds the trust needed to improve health and eventually produce downstream savings.

The growth drew the attention of researchers who made a case study of one Anovia employer client and found a savings of $684,000 in 2025 among 153 employees, along with a 14% drop in cost per employee, Singh said. Patient and provider satisfaction scores were high as well. The comparison was based on a full episode of care for employees using Anovia versus those who weren't, she said, and Anovia hopes to replicate the results as it studies other employer partnerships.

What a national survey found

A new survey from the Direct Primary Care Alliance found the model succeeding in urban, suburban and rural communities alike, without being tied to any one type of location or demographic, Smith said. The survey also found that a majority of respondents were female physicians, something Smith attributed in part to the flexibility direct primary care can offer physicians balancing work and family responsibilities. Nationally, the average direct primary care membership costs about $98 a month, she said, a figure she said helps clarify how different the model is from concierge medicine or capitated insurance plans, which people often assume it resembles.

AI in day-to-day practice

At Anovia, physicians and advanced practice providers are testing an AI tool built for peer chart review, giving clinicians feedback on things like referral patterns and test selection in a collaborative, non-punitive way rather than through formal performance review, Singh said. The tool was developed by a family physician identified only as Dr. Paulius in the discussion, she said, and Anovia is still working out how broadly to use it.

Hobbs described two broad categories of AI use in direct primary care. The first treats AI tools as something like "fractional employees," handling marketing, scheduling or other business functions a small practice couldn't otherwise justify hiring for. The second addresses the shortage of primary care physicians more broadly, using AI to field the steady stream of patient questions, messages and calls that come in outside office hours. He cited research from OpenAI showing that roughly seven in 10 health-related queries happen after hours, a gap he said AI is well-positioned to fill.

In his own practice, Hobbs uses an AI scribe for patient visits that lets patients revisit a transcript and ask follow-up questions afterward, since research shows people often forget most of what they were told within 20 minutes of a visit. He also uses an AI receptionist, clinical decision support tools patients can access directly, and a clinician-facing scribe that surfaces relevant recent literature alongside his notes, which he described as a way of keeping his own knowledge fresh.

Pastoor, who also practices direct primary care, said AI-driven clinical decision support has cut down her own need to refer patients out, limiting referrals mostly to complex diagnostic cases or procedures.

Barriers to wider adoption

New physicians entering direct primary care often lack the volume of patient experience that comes from years in traditional practice, Hobbs said, and he suggested the model may need a formal mentorship or apprenticeship structure to help new graduates adjust to seeing patients without that background.

Direct primary care remains in a "pioneering phase," Smith said. She described a conversation with a colleague who compared the field's founders to bushwhackers clearing a trail, with today's physicians more like settlers who at least have a roadmap to follow. Even so, she said, much of the field's physician base has an entrepreneurial streak that won't appeal to every doctor. Opening the model to physicians who don't see themselves as pioneers or rebels, and who simply want to practice medicine rather than run a business, is one of the field's biggest access points to fix, she said.

Singh pointed to "golden handcuffs," including noncompete clauses, loan repayment obligations and job security, as reasons many physicians stay in traditional employed roles. Overcoming those barriers, she said, will require greater exposure to direct primary care in medical schools and other health training programs. DPC also needs more employment options like the ones Anovia offers, where physicians can work as employed clinicians without being required to become practice owners or partners. Moving away from a relative value unit-based pay model, in favor of team-based incentives, has been an important part of Anovia's approach, Singh said, since it better reflects how the practice's physicians, advanced practice providers and nurses share responsibility for patient care.

Policy asks

Smith compared her old insurance-based practice to a slow-moving barge that was starting to list, and described leaving fee-for-service medicine as jumping to a smaller, more nimble boat she could actually steer. That makes it harder to advise policymakers now on fixing the system she left, she said, but she believes patients should be put back in the driver's seat.

"I think the idea of using HSA dollars and putting those in the hands of the patient and allowing them to spend them where they see fit is a true innovation," Smith said. She added the idea makes some policymakers “a little scared to think about that” even as it points toward where she thinks primary care is headed. Untangling primary care from insurance-driven reporting and coding requirements would also help the model grow, Smith said.

Figuring out how direct primary care fits into Medicare and Medicaid is both the biggest remaining challenge and the biggest opportunity, because patients often move between employer coverage, Medicaid and Medicare over their lifetime, and practices want to preserve that relationship through each transition, Singh said.

Universal vaccine coverage for all children at all ages, regardless of how they're insured, is the single biggest policy fix pediatric practices need, Hobbs said. Without it, “if you can’t get the patients, you can’t keep the doors open,” he said.

Looking ahead

Family medicine has long struggled with something of an identity crisis, Smith said, describing an unspoken assumption within medicine that the specialty is a fallback rather than a first choice. She said she hopes that within five years, every medical student knows direct primary care exists and sees primary care broadly as a desirable path rather than a consolation prize, something she believes could help double the primary care workforce.

Singh said she expects direct primary care to keep expanding to reach more patients, with artificial intelligence playing a role that's still hard to predict, though she said the model's success will still come down to having enough people, resources and investment behind it.

Hobbs said his hope is simpler: that direct primary care becomes such a household name that demand outpaces the number of physicians available to practice it. “Everyone knows what it is, everyone's looking for it, and they can't find it because there's just not enough because the demand is so high,” he said.