The DPC model has faced its share of criticism. My first viral post was a rebuttal to a misguided JAMA article where I addressed many of the common misconceptions levied against the model. I’ve continued to engage in plenty of conversation with others who don’t quite understand the model or what the community is building. When going against the prevailing system, there is often an air of superiority of those still in the system and “they” like to criticize DPC physicians with “how dare you” statements. In reality, “they” who continue to stay in the broken system are truly the ones to whom that question should be asked.  

“How dare you abandon the poor?”

First of all, no one should group “the poor” into one convenient talking point. Healthcare disadvantages people in a few ways 

The working poor: Someone who technically has insurance but cannot afford to use it. They pay the premium, avoid the deductible, delay the test, skip the visit. For this patient, the traditional system offers the illusion of protection wrapped in opaque prices. DPC can be the difference between avoiding care and getting care. It can mean a same-day visit instead of an urgent care bill, a $5 cash-pay medication instead of a formulary game, a transparent lab price instead of a mystery invoice, and a doctor willing to help navigate the cash-pay world because the insurance world has become too expensive to touch. 

The complex-care poor patient: Someone who gets punted from specialist to specialist because no one has the time, incentive, or relationship to hold the whole story. Cardiology manages one organ; endocrinology another. Psychiatry adjusts one medicine; the hospital adds three more. The patient becomes a stack of consult notes, bills, and contradictions. Good primary care reduces this chaos. Not by replacing specialists, but by making specialist care more selective, more coordinated, and less reflexive. A strong primary care physician can deprescribe, consolidate, explain, monitor, and sometimes prevent referrals that never needed to happen. 

The truly indigent patient: The one for whom Medicaid exists. The government often cannot get out of its own way. A Medicaid card does not guarantee a physician. A benefit does not guarantee access. A directory does not guarantee an appointment. The system is so broken that some Medicaid patients still pay for DPC because they need what the card could not reliably buy: time, access, relationship, and someone who answers. 

How dare they build a system where the working poor are insured but afraid to use care, the complex poor are fragmented into billable body parts, and the truly indigent are handed a card without enough places to use it. 

How dare they underfund primary care, overcomplicate access, and then blame the doctors trying to create a front door that actually opens. 

“How dare you charge patients a monthly fee?”

“How dare you charge a monthly fee on top of insurance?” is the actual accusation. Not that DPC charges for care. That DPC charges for care when patients already have insurance. 

But look at what “already have insurance” means. 

It means high premiums before anyone gets sick followed by denials when they do. It means deductibles large enough to make a doctor visit feel like a financial decision. It means prior authorizations, narrow networks, denied claims, surprise bills, and formularies that change without asking the patient or the physician. It means a family can do the responsible thing, buy coverage, pay every month, and still avoid care because they are afraid of the bill. 

And hospitals? Hospitals get to charge opaque prices, send facility fees, pursue collections, and in some cases sue patients who could not pay. Somehow that became normal. 

But a primary care doctor saying, “Here is my price. Here is what is included. Here is how to reach me. Here is what your labs and medications cost. Here is how I will help you avoid unnecessary visits, unnecessary specialists, unnecessary imaging, and unnecessary bills,” is treated as scandalous. 

DPC did not create the double-payment problem. The insurance system did. 

DPC is the predictable part. The transparent part. The part where the patient knows the price before the care happens. A low monthly fee is not the insult. The insult is paying hundreds or thousands of dollars per month to an insurance company and still being told no. 

How dare they build a system where patients pay premiums for the privilege of not meeting their deductible, where care can be denied after coverage is purchased, and where hospitals can send life-altering bills after the fact. 

How dare they call DPC the extra cost when, for many patients, DPC is the only part of health care that finally makes financial sense. 

How dare they allow insurance to become so expensive, so opaque, and so unreliable that patients pay for coverage and still cannot afford care. 

“How dare you reduce your panel size?”

Traditional primary care likes to believe that if every patient is assigned to a doctor, every patient has a doctor. 

The math does not work. A 2022 study estimated that a primary care physician would need 26.7 hours per day to provide guideline-recommended preventive, chronic, acute, documentation, and inbox care to a typical panel. Even with team-based care, the estimate was 9.3 hours per day. 

Without time, primary care becomes triage with nicer lighting. With time, a doctor can understand, coordinate, explain, prevent, notice, follow up, and occasionally ask the question that changes everything. 

How dare they create impossibly large panels, call it “access,” and then shame physicians for designing practices where patients can actually be known. 

“How dare you not take insurance?” 

Insurance is useful for large, unpredictable, financially dangerous events. That is the point of insurance. Somewhere along the way, we decided it also needed to mediate the relationship between a patient and a primary care doctor. The result has been predictable. Coding, claims, prior authorizations, denials, and administrative work disguised as care. 

Primary care fed only on insurance becomes malnourished. It may still look alive. The lights are on. The portal works. The schedule is full. But the relationship is starving. 

DPC rejects insurance billing for primary care because the billing system has eaten the care. 

How dare they turn insurance into the operating system for every sore throat, school form, refill, rash, blood pressure check, and portal message. 

“How dare you avoid quality metrics?”

Quality metrics are not inherently bad. Measuring blood pressure control, diabetes care, cancer screening, and medication safety can be useful. The problem begins when the measurement system becomes so bloated that it starts consuming the clinical system it was supposed to improve. 

A JAMA Health Forum study found that primary care physicians in one large system faced an average of 57 unique quality measures across value-based contracts. At some point, this stops being quality improvement and starts being a scavenger hunt. 

DPC is not anti-quality. It is anti-theater. 

Quality is not just a checked box. Quality is a patient who can reach the doctor before the emergency. Quality is catching the side effect before the cascade. Quality is knowing the patient well enough to understand why the plan failed. 

How dare they bury primary care under quality paperwork and then accuse DPC of lacking accountability because it refuses to worship the clipboard. 

How dare they confuse measurement with meaning. 

“How dare you cherry-pick healthy patients?” 

The sickest patients need time. They need medication reconciliation. They need follow-up. They need someone to call the specialist, review the hospital discharge, explain the plan, and notice that the “noncompliant” patient cannot afford the medicine. 

Traditional payment rarely rewards that work properly. Fee-for-service rewards visits and procedures. Value-based care often rewards documentation, attribution, coding, and risk adjustment. Insurance rewards whatever survives the contract. 

DPC rewards the relationship. 

A complicated DPC patient is not a billing problem. A complicated DPC patient is the reason the model exists. 

Does every DPC practice serve the same population? No. Does every practice solve every access problem? No. But the accusation that DPC is inherently built for the healthy misunderstands what many patients are buying: time, access, coordination, and a doctor who is not sprinting toward the next room. 

How dare they make the sickest patients navigate the most fragmented version of medicine and then criticize a model that gives them more direct access to a physician. 

“How dare you fail to solve catastrophic health costs?” 

DPC is primary care. It is not chemotherapy. It is not trauma surgery. It is not an ICU. It is not a substitute for catastrophic coverage. This criticism is like accusing a fire extinguisher of not being a fire department.  

Patients still need insurance or some form of protection for major expenses. DPC physicians should say this plainly. The model is strongest when paired with sensible coverage for catastrophic events. 

But the fact that DPC does not solve every cost problem does not mean it solves no cost problem. Primary care is where many costly cascades begin or are prevented. It is where symptoms are sorted, medications are cleaned up, unnecessary referrals are avoided, hospital follow-ups are stabilized, and chronic disease is managed before it becomes an ambulance ride. 

Milbank’s 2026 report found that adults with chronic disease who had a usual source of primary care were 20% less likely to have a hospitalization and 11% less likely to have an emergency department visit than those without one. 

How dare they underbuild primary care and then act surprised when the expensive parts of the system overflow. 

“How dare you worsen inequity?”

The current system has a remarkable ability to hide inequity inside complexity. It gives people insurance plans with narrow networks and calls it access. It gives them deductibles they cannot afford and calls it coverage. It gives them a list of in-network doctors who are not accepting new patients and calls it choice. 

That is not equity. That is paperwork with a logo. 

DPC can worsen inequity if it becomes only a boutique option for people with disposable income. That concern deserves to be taken seriously. 

But DPC can also improve equity if employers, unions, churches, nonprofits, Medicaid programs, municipalities, and states use it to buy actual primary care access for people who currently have none. 

How dare they call DPC inequitable while tolerating a system where the poor get access gaps, the working class gets deductibles, and the middle class gets network roulette. 

How dare they defend a status quo that is inherently inequitable. 

“How dare you make medicine about physician happiness?”

Physician burnout is not mainly a doctor problem. It is a patient access problem. Burned-out doctors retire early, sell to hospitals, close panels, leave primary care, reduce hours, stop teaching, or leave medicine entirely. 

The AAMC projects a physician shortage of up to 86,000 physicians by 2036. HRSA reported that, as of March 31, 2026, more than 101 million people lived in designated primary care Health Professional Shortage Areas. 

So yes, physician happiness matters. Not because doctors deserve artisanal work lives, but because a physician who can keep practicing is part of the access solution. 

How dare they ignore physician sustainability until patients cannot find a doctor. 

“How dare you step outside the system?” 

How dare they keep calling this a system. 

A system has design. A system has accountability. A system has coherence. What we have is a billing apparatus masquerading as medicine. 

DPC is not perfect. It is not the only answer. It will not solve every problem in American health care, and anyone claiming otherwise should be treated with the same suspicion as a consultant with a five-step framework. 

But DPC does something rare: it starts with the clinical relationship and builds outward. 

For decades, primary care has been told to survive on scraps while being asked to solve everything: chronic disease, behavioral health, access, cost, prevention, quality, patient experience, opioid stewardship, transitions of care, social determinants, portal messages, and every form that begins with “just.” 

The result is predictable. The United States spends less than 5% of health care expenditures on primary care, while more than 30% of adults lacked a usual source of care in 2022. 

This is the soil from which DPC grew. 

It grew because some physicians looked at the rushed visits, billing games, inbox overload, quality theater, access fiction, and administrative obesity and said, “No thank you. We are going to try something else.” 

That “something else” is still evolving. It will need discipline. It will need humility. It will need guardrails. It will need to reach beyond the patients who can easily pay. It will need to prove itself not only as a refuge for doctors, but as a serious access model for communities. 

When critics misunderstand the purpose or potential of the model, they may say “How dare you…”  

There is simply one answer to this charge: We dare because we care.