Design or Be Designed

Direct primary care earned its place in healthcare system conversations by building durable practices on patients who pay directly and stay. That loyalty is the model’s power, and the movement is now deciding what to do with it. Employers and governments pay for about 80% of American healthcare, all of it, not just the primary care slice DPC occupies; and they cannot buy primary care in a piecemeal fashion the way a family can. Reaching them takes structures that make DPC legible to large buyers without surrendering the clinical relationship that made it worth buying. 

DPC practices are funded by patients who pay directly and therefore can keep their doors open without anyone else’s permission. No single outside contract is load-bearing. A practice that sustains itself on its own panel does not need an employer deal, and one that does not need a deal can negotiate on its own terms, or walk away from a bad one. That independence is the real source of a practice’s strength, which is why engaging employers is best understood as a way to diversify rather than a lifeline to survive on. None of this sidelines the patient. Strip the direct relationships out and there is nothing left to negotiate with.

A recurring argument follows that if patients are the point, shouldn’t patients pay the bill themselves? That conflates two different things. Alignment is not the same as funding. Being patient-driven means the dollars, the accountability, and the design answer to the patient. It does not require the patient to write the check. Employer or government funding can still be patient-driven. The test is simple: does the funding preserve the patient’s agency, and does it keep the clinical relationship out of an institution’s hands? Direct payment obviously passes that test, but it is not the only thing that can.

Putting the patient at the center also means looking past primary care itself. A patient’s needs run well beyond the clinic to specialists, hospitals, imaging, pharmacies, therapists, the emergency room, and the insurance rules over it all. Primary care’s job is to be the patient’s advocate across that whole landscape, carrying transparency, portability, and support through every door. Serving the whole patient is a reason to engage the wider system, not retreat.

Employers fund care for about half the country, and one covering thousands of lives needs predictable cost, predictable quality, and one number to call when something breaks. The quality issue is the movement’s to address. “Trust me, the care is good” is not an answer. Earning trust means defining what doing this well means and putting that standard in the open, not asserting excellence and resenting the question.

DPC makes the buyer’s job harder, and does so on purpose. The movement is proud that if you have seen one DPC, you have seen one DPC. That variation is a feature for patients and a problem for anyone asked to credential, audit, invoice, and troubleshoot twenty practices one by one. So the buyer wants a single accountable counterparty and someone who owns the implementation. An aggregator, an MSO (or PCMO for those who keep trying to make fetch happen), or a network administrator exists to be that counterparty. The care still happens on the block; the paperwork simply has to live somewhere.

An often referenced analogy actually proves the point. Some think that most families hire a kid with a mower in each town rather than dealing with landscaping conglomerates. In reality, more than half of U.S. lawn care is contracted at the enterprise or HOA level, which is exactly the intermediation the analogy was supposed to rule out. Buying groceries is another frequently cited example. Yet, grocery stores too are middlemen aggregating thousands of products to one place where consumers can shop. Direct markets organize themselves through intermediaries once they reach any size, and DPC is no exception. By Hint’s 2026 report, roughly 60% of DPC members are now employer-sponsored, split between enterprise and individual buyers in much the way lawn care is. 

The term “mom and pop” lands as an insult only to those determined to hear one. A neighborhood bakery is not a failed chain; in fact many people prefer their neighborhood shop. A solo practice and a multi-state, employer-contracted group operate differently but share an identical philosophy. The real distinction is not small versus large, but whether growth preserves clinical independence. Dr. Jon van der Veer started as a single-physician practice and never imagined operating across state lines as he now does in partnership with the grocery chain Hy-Vee. Dr. Kyle Rickner ran his own panel for years before local employers came calling. He then grew Primary Health Partners to meet the challenge while maintaining the autonomy and simplicity he wanted when he was practicing on his own. Neither abandoned the core principles of the model while growing; they scaled it. 

A practice that lets one aggregator or employer become its entire panel gives away what made it worth contracting with, turning diversification into dependence. Sign the contracts, but never let the direct base thin out, and the freedom to walk away stays. A system is forming around DPC regardless. Practices that keep the patient relationship at the center negotiate as equals; those that trade it away become a line item in another network. The patient is the model whether the payer is a household, an employer, or the state. Hold that center, and DPC designs the system. Lose it, and the system designs DPC.