Dr. Julie Gunther was burned out. After eight years in family medicine in Boise, Idaho, she was juggling 2,300 patients. Appointments lasted seven minutes. New patients waited three months for a slot. The pace destroyed her relationships and her health. She came home angry. Tired. This wasn’t the medicine she trained for.

She needed out.

In 2013, Gunther found direct primary care. It’s a simpler model. No insurance billing. No copays. Patients pay a flat monthly fee. She started Spark MD in 2014. She caps her panel at 600 patients. Adults pay $79 a month. Kids pay $10. Seniors over 90 pay nothing.

The trade-off is clear. You pay cash. You get access.

Appointments run over an hour. Patients call her cell phone on weekends. Same-day sick visits are standard. Lab tests and X-rays cost a fraction of retail prices. Her in-house pharmacy sells generic meds cheaper than big-box stores, even with insurance coverage.

“It’s the gold standard for high-quality primary care,” Gunther says. “If someone calls in right now, they can get in today. That fundamentally changes the entire structure of how you take care of people.”

How direct primary care works and costs

DPC is growing fast. When Spark MD opened, it was only the 124th clinic in the U.S. Today, there are more than 1,000. The American Academy of Family Physicians reports that 3% of its members use the model. Another 3% are switching.

It’s not just solo practices. Some DPC clinics are large corporate operations for employees.

Don’t confuse DPC with concierge medicine. Concierge doctors often still bill insurance. The membership fee buys better access and extra services not covered by plans. DPC cuts the insurance layer entirely.

Why are doctors switching? They hate the red tape. They want to treat patients, not fill out forms.

Why do patients sign up? Transparency. The price is fixed. No surprise bills. Plus, paying cash often saves money on prescriptions and labs compared to insured rates.

Critics aren’t buying the hype. They worry DPC widens the gap between rich and poor. If you can’t afford the monthly fee, you lose your doctor. It might create a shortage of primary care for those who need it most.

Is direct primary care better than traditional insurance?

Dr. Paul George is skeptical. He’s an associate dean at Brown University’s Warren Alpert Medical School. He co-authored a 2018 JAMA opinion piece attacking the DPC model’s claims.

Proponents say DPC lowers overall healthcare costs. They claim fewer hospital visits and happier patients.

George says there’s no proof.

“There’s no data whatsoever,” George says. “You can’t really tout something as the next great, big thing without showing us the evidence.”

He admits DPC doctors are happier. Longer visits help. Relationships improve. But he worries about the patients left behind.

When a doctor drops from 2,300 patients to 600, 1,700 people need new doctors.

“They’re saying, ‘If you can afford our fees, you can join us. If you can’t, you have to look for a new primary care doctor,'” George says.

He calls it inequitable. Maybe even amoral. It clashes with the Hippocratic oath to treat everyone regardless of status.

The DPC model offers a better experience for those who can pay. But it raises a hard question. Who takes care of the rest?

Why Critics Call DPC Inequitable

George isn’t just critiquing the business model. He sees a deeper flaw. Direct primary care feels inherently unfair. It favors people with higher incomes. These patients tend to be healthier than their poorer neighbors. The math doesn’t work for everyone.

Most DPC patients still need insurance. They buy high-deductible plans. This covers emergencies. It covers surgeries. It even covers childbirth. You can’t rely on a monthly fee for a broken hip.

There is a legal hurdle too. HSA funds cannot pay for DPC membership fees. You can use them for meds and labs at those clinics. That’s it. Gunther notes only a third of her patients go completely without insurance.

George asks a hard question. How do lower-income people pay? They face a few hundred extra dollars a month for DPC. Plus insurance premiums. Even with a cheaper high-deductible plan. The stack gets high fast.

“For many patients, that’s not affordable,” George says. He points out the lack of proof. There is no outcome data. Buying extra access might not help their health at all.

Defending DPC Against Cost and Access Claims

Gunther pushes back. She says cost isn’t a barrier. Most of her patients have supplemental insurance. Some get it through employers. Others use Medicare or Medicaid.

She believes DPC saves money. Not just a little. Thousands. Maybe tens of thousands.

Look at the prescription savings. One patient had a great employer plan. Still paid $10 a month for each of six generic drugs. Gunther runs a wholesale generic pharmacy. She saved that patient $550 a year on meds. That nearly covers the yearly DPC subscription.

Then there is the clinical efficiency. A patient came in with an orthopedic issue. Gunther’s nurse practitioner spotted a pre-cancerous skin lesion. They removed it at the next visit. The bill was $85. If Gunther had been in the office, it would have been same-day.

Compare that to traditional care. An insurance-billed primary care doctor would require a referral. You wait weeks for a dermatologist appointment. You pay hundreds in surgical and pathology fees.

George claims DPC docs violate their Hippocratic oath. He says they leave hundreds of patients behind.

Gunther disagrees. She argues many of those patients rarely came in. They used urgent care instead. That is accepted practice. She wasn’t doing the work she wanted to do anyway.

Is Direct Primary Care Right for Lower-Income Families?

Gunther wants a societal shift. We need to rethink patient load. Public schools have limits on class size. Why not medicine?

“If you take care of somebody full-time as authentically as you can, where is that number where an individual physician is full?” she asks.

She doesn’t speak for all DPC physicians. But she rejects the idea that DPC only serves the healthy and wealthy. She also denies the myth that these doctors make piles of cash while seeing fewer patients.

Most are not earning what they did before. Some make double their prior salary. Most make under $100,000. That isn’t competitive for an entrepreneur or a physician. But they trade salary for autonomy. They want to practice the way they want.

George isn’t rooting against DPC doctors. He wants data. In the year since he criticized the model in JAMA, no peer-reviewed DPC study has been published.

“I’ll eat my words,” George says. “If your model is showing that it’s beneficial to physicians, beneficial to patients, that you’re reducing health care costs, and that there’s no social inequity, then I’ll eat my words. But prove it!”

Alternative Coverage for DPC Patients

A growing number of Gunther’s patients skip conventional insurance. They join health care sharing ministries. These are private Christian organizations. Believers pool resources. They provide lower-cost health coverage. It is a niche solution. But it highlights the flexibility some patients seek outside traditional systems.