It was interesting to see this week a PCP featured in The Free Press talking about their decision to launch their own Direct Primary Care (DPC) practice. This follows a Health Affairs article last week suggesting that the number of clinicians participating in DPC grew from ~4,000 to ~7,000 between 2018 and 2023. The Free Press article includes a heady title talking about practicing medicine “the way it should be done”:

It all has me curious about how much we’re talking about DPC in 2026 and whether it will exit the niche status it has occupied over the last few decades.

Like most “new models” in healthcare, DPC/concierge clinics are anything but new. The concept dates back at least 20 years to efforts like Qliance in the mid-2000s and concierge practices dating back to the 1990s. It’s not hard to see the conceptual appeal for an enterprising provider who is burnt out by the system. If you charge $3,000 per year for a membership, as the provider in the article above does, at 150 patients, you’re bringing in $450,000 in annual revenue. And that’s before you add in any other potential revenue streams, i.e., longevity stuff. That sounds pretty nice, right?

It seems there are three key potential tailwinds for DPC at the moment: 1. provider dissatisfaction with the current state of the healthcare system, 2. OBBB changes to federal tax laws so that DPC can be paid for out of HSAs, and 3. a growing public interest in preventive care/longevity. Any one of these seems meaningful; all three together could catalyze the market.

The key headwind for DPC has generally remained consistent over time — fewer people are willing to pay for DPC than proponents expect. This has been true for venture-backed models like Qliance, which shut down in 2017. It has also proven true for health system-backed efforts, like Spectrum Health’s STRIVE clinic. And it’s also been challenging for countless independent providers. Southdale Internal Medicine seems like a good example of this. Back in 2013, it was a practice that went DPC with five physicians, after being founded in 1982. Today, there is one provider left in what appears to be the remaining version of that practice. If you check out the website, it now highlights the benefits of being a fee-for-service practice(!!) that offers “better-than-concierge medicine for adults with no annual fee.” It’s a fascinating counterpoint to the broader industry narrative against fee-for-service medicine.

We discussed the DPC momentum on Slack this week, and Connor Allen brought up the example of Primary Health Partners in Oklahoma as an example of how these dynamics might be changing. That DPC practice has scaled to ~25 physicians across 10+ locations. Connor made a strong case for the opportunity to build ~$100 million DPC businesses in metro areas that are cash flow positive and generate strong margins. The crux of the conversation is the percentage of the people in a metro area who would flip to a DPC model. If you believe 5% - 7% of a metro would pay for DPC, I tend to agree with Connor that a meaningful business could be built in a market. Yet I also think that historically, this number has been challenging to hit for a variety of reasons. The question is whether the tailwinds above make it more feasible in today’s environment.

The willingness-to-pay issues are ultimately why I remain in the camp that DPC will continue being a niche offering moving forward, barring some much more meaningful regulatory change in how primary care is paid for in the US. That said, I also can’t blame a provider for wanting to test out if they can build a practice on their own terms, and some of them will be successful in doing so. Many will also not be successful, but such is the nature of choosing an entrepreneurial path.

I have a feeling that high-quality (however one chooses to define it) PCPs will be in greater demand than ever over the next few years, and that question of where those PCPs will decide to work is worth keeping an eye on.

Given this audience is a relatively well-educated healthcare audience, I’m curious what DPC use trends look like in this audience:

As Martin covered in his policy roundup this week, early CMS data suggests that ACA marketplace enrollment numbers are coming in quite hot, almost 12% ahead of last year at this time. Long-time ACA sage Charles Gaba dissected the trends well in this post, highlighting the numbers this year compared to last year:

Given the general predictions of a decline in the ACA population, it seems counterintuitive that enrollment numbers are running hot compared to last year. Perhaps all the uncertainty has prompted people to shop earlier in this year's enrollment window.

Still, if you look at the state-by-state breakdown in Gaba’s post, you’ll see some states like Georgia have a 70% increase year-over-year, while some states like Colorado have a 30% decrease.

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