$5,000 a Year Is Direct Care's "Bottom Row." Patients Should Hope It Stays There.

Every market eventually gets a map drawn by the people who sell its businesses. Direct primary care just got ours.

In October, the health care advisory firm Vector Medical Group and the law firm Baker Donelson published a white paper called State of Concierge and Consumer Medicine, 2026. It sorts membership medicine into 4 tiers by annual fee. Direct primary care sits on the bottom row, labeled "Standard/DPC": under roughly $5,000 a year, with 400 to 600 or more members per physician.

The tier above it, $5,000 to $15,000 a year with 150 to 400 members per doctor, is "where most sponsor-backed platform formation is concentrated," the paper says. Translated: that's where the investment money is going. One platform in the paper's tables charges a $30,000 base fee per member each year.

The authors advise on deals, and they say what deal people value out loud. In membership medicine, they write, the asset "is a renewing relationship." Value gets built with add-ons that "raise revenue per member without raising panel size": diagnostics, hormone optimization, weight management, wellness, aesthetics.

I don't fault anyone for reading a market that way. It's their job. But read that sentence again as a patient. A renewing relationship is an asset. Your trust is the thing on the balance sheet.

Here's what the bottom row actually looks like. The American Academy of Family Physicians puts typical direct primary care fees at $50 to $100 a month. That's $600 to $1,200 a year, a long way under $5,000. For that, a patient gets a doctor's cell number, same- or next-day visits, and labs and generic medications at prices you can see before you agree to them.

That's not the cheap seat. That's the design.

The paper calls the bottom tier the "broadest addressable market." I'd put it more plainly. It's where the plumbers, teachers, farmers, and small-business owners are. It's the carpenter with a $7,000 deductible and the travel nurse who couldn't afford his agency's plan. They don't need hormone optimization. They need someone to look at the rash, refill the blood pressure pill, and answer the text at 9 p.m.

There's a practical line, too. Since January, a qualifying direct care membership can be paid with HSA money without closing the account to new contributions, as long as it's primary care only and the fee stays at or under $150 a month for one person. Climb past that and members can still spend from the HSA, but they lose the ability to keep adding to it. Under the new federal rules, the bottom row is the only row that fits.

The paper says one more thing worth repeating: "Cash-pay does not mean unregulated." Good. Patients deserve that protection, and honest practices welcome it.

So let the capital build the $15,000 tier. Somebody will buy it. Direct care was never supposed to be a luxury good with a stethoscope. It was supposed to make the front door of medicine affordable enough that people walk through it early, while the problem is still small.

If you're choosing a membership this fall, ask 3 questions the deal teams ask, from the other side of the table. What does it cost each month, all in? What's included without an add-on? And who owns the practice: the doctor, or a fund that needs the fee to rise?

The bottom row is where most of America lives. It's the best place in medicine to practice.

$7 Million to $194 Million: Medicare Turned a Phone Call Into a Billing Code

Dianne Williams lives in rural Georgia. Every day she straps a cuff to her arm and presses a button. The reading goes to her doctor and to a nurse who calls her once a month.

When her pills weren't bringing her pressure down, that nurse told her to start walking and eating better. Now she walks a local track every day. She bakes her fish instead of frying it. She lost weight. Her pressure came down.

"They just didn't just take my blood pressure and that was it," she told KFF Health News.

That's medicine. A number, a person who looks at it, and a conversation that changes what happens next.

Now Medicare may take it away. Arielle Zionts reported for KFF Health News that a proposed CMS rule would stop paying clinicians who use outside tech companies to run remote monitoring. Medicare would pay only when someone at the clinician's own facility does the work. Williams' clinic, a community health system already running "borderline understaffed," says it couldn't offer the program without a vendor. "It looks like they're cutting off everybody," Williams said, "and that's not right."

She has a point. So does Medicare.

Traditional Medicare spent just under $7 million on remote physiologic monitoring in 2019. By 2023 it was more than $194 million. Enrollment grew tenfold, and patients stayed on it longer, from 1.7 months on average to 5.2. Some vendors sell the service to clinics as a way to generate income. Caroline Pearson of the Peterson Center on Healthcare put it plainly: paying doctors to review huge numbers of readings for years on patients whose blood pressure is already controlled "doesn't feel like a clinically driven decision. That feels like a revenue decision."

Both things are true. The nurse's phone call helped Dianne Williams. And the billing code that paid for it grew into a business.

This is what happens every time we turn a relationship into a reimbursement. We needed a code for the cuff, a code for the review, a code for the call. Then a company to bill the codes. Then an inspector general report about the company. Then a rule to police the report. Now a fight over the rule, with more than 230 groups signed on against it and Humana, the Blue Cross Blue Shield Association, and Sutter Health in favor.

Nobody in that fight is asking the simplest question. Why does a doctor need a billing code to look at a patient's blood pressure?

In direct primary care, she doesn't. A patient pays a flat monthly fee. She buys a cuff at the drugstore, takes a reading, and texts the number to her own doctor. The doctor answers. If the pills aren't working, they change the pills that week. If it's time to walk the track and bake the fish, the doctor says so, and the doctor knows her well enough for it to land. No vendor. No code. No minimum number of readings to qualify for payment. No incentive to keep a controlled patient on monitoring for years, because nobody gets paid more for it.

When the pressure is controlled, the texts slow down. When it isn't, they speed up. That's what Pearson says the evidence supports: use the data to change treatment, then stop once the patient is stable. Direct care does it by default, because the doctor's time is already paid for and nobody is counting readings.

I'm not against remote monitoring. I'm against paying for it in a way that makes the reading more valuable than the patient. Rural clinics will lose real services if this rule goes through as written, and some fix is needed. But every version of the fix still runs through the same machine: Washington writes a code, someone games the code, Washington writes a rule.

The cheapest way to watch a patient's blood pressure is to give her a doctor she can text.

Dianne Williams found something that worked: a nurse who knew her and called her once a month. That shouldn't depend on a billing code. It should be part of having a doctor.

Find a direct care practice near you, or get stories like this in your inbox at directcare.org/newsletter.

Source: Arielle Zionts, KFF Health News, "Many Medicare Patients Could Lose Access to Remote Monitoring Devices" (Oct. 26, 2026): kffhealthnews.org/medicare/remote-patient-monitoring-cms-medicare-rule-reimbursements-access-rural-health/

193 Counties Have Zero Medicare Advantage Drug Plans for 2027

"Reached my golden years. Need Medicare Advantage if I can find it."

A reader named Ross Burnett sent that 17-syllable haiku to KFF Health News as Medicare open enrollment got underway, and the federal data for 2027 backs up every word of it.

Roughly 35 million older and disabled Americans are enrolled in privately run Medicare Advantage plans. According to KFF's review of the 2027 landscape reported by ABC News, the average Medicare beneficiary can choose from 35 Medicare Advantage plans for 2027, down from 39 plans in 2026.

In rural and smaller markets, the pullback is sharper. Across 193 counties, beneficiaries will have zero Medicare Advantage prescription drug plans available during general enrollment for 2027, up from 123 counties in 2026.

At the same time, major carriers are trimming their footprints. UnitedHealthcare is ending Medicare Advantage plans covering roughly 390,000 people, and Humana is exiting plans covering about 600,000, mostly preferred-provider-organization plans that gave seniors wider access to out-of-network doctors.

And the prescription drug math is shifting beneath seniors' feet. The federal Part D Premium Stabilization Demonstration, a temporary subsidy that the Medicare Payment Advisory Commission found lowered average monthly standalone drug plan premiums by $26 in 2025 and $16 in 2026, expires at the end of the year. Meanwhile, the standard Medicare Part D deductible rises from $615 in 2026 to $700 in 2027.

Washington University health policy professor Timothy McBride gave the warning every senior and adult child needs to hear before Medicare open enrollment closes on Dec 7: "I think people need to be paying attention to not just the premium, but also things like the deductible and the caps because that could significantly impact their out-of-pocket costs."

When a Medicare Advantage plan pulls out of a county or narrows its network, seniors discover something painful: holding an insurance card is not the same thing as having a doctor.

That is why so many retirees, and the adult sons and daughters who help them sort through plan booklets every autumn, pair Medicare with a direct primary care membership.

Your Medicare coverage is still there for hospitalizations, specialist procedures, imaging, and expensive brand-name prescriptions. Your primary care, however, steps off the insurance carousel. For a flat monthly fee, an older patient gets unhurried 30- to 60-minute visits, a doctor who answers the phone without a call-center tree, wholesale prices on common generic medications that often beat Part D copays, and a physician who stays the same even when the plan in the mailbox changes between Oct 15 and Dec 7.

Check the 2027 plan directory before Dec 7. Make sure the hospital and the drug list still work. Just don't let an insurance carrier's county map decide who takes care of your parents.

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90% of Your Doctor's Referrals Can Belong to the Hospital by Contract

Turn to page 77550 of Volume 85 of the Federal Register, published in December 2020, and you will find one of the most consequential sentences in American medicine.

A public commenter asked the Centers for Medicare & Medicaid Services whether a hospital could terminate an employed physician's contract if the doctor failed to send a set percentage of referrals to the hospital's own network.

CMS answered yes, and worked the commenter's own number into the final rule: a 90% referral requirement, enforced by contract termination, is lawful under 42 CFR 411.354(d)(4)(vi).

As healthcare analyst Dutch Rojas detailed in The Rojas Report, federal Stark rules forbid a hospital from paying a doctor a bonus for each referral. What the rule expressly allows, however, is a signed employment contract requiring a salaried physician to route an established percentage or ratio of referrals, 80%, 90%, or more, to the hospital that signs the paycheck.

On paper, the regulation includes 3 carve-outs. The quota doesn't apply if the patient expresses a preference for a different provider, if the patient's insurer dictates where to go, or if the physician decides an outside referral is in the patient's best medical interest.

In a 12-minute appointment inside a hospital-owned clinic, how often does a patient know to invoke a federal regulatory override?

The electronic health record defaults to the hospital's imaging center, the hospital's outpatient lab, and the hospital's specialist down the hall. The physician wants to keep her job. The patient assumes the referral was chosen for quality and value, right up until the hospital facility fee arrives in the mail.

Dr. Dan Swartz, a family physician in West Michigan, recently borrowed a term from wealth management to describe the alternative. He calls a direct primary care doctor a "health fiduciary."

In finance, a fiduciary is bound to act solely in the client's best interest rather than steering the client toward house-brand funds that pay a commission. In medicine, an independent direct primary care physician has the exact same alignment. Because the doctor is paid directly by the patient through a flat monthly membership, and owns no stake in a hospital tower, there is no referral quota in the desk drawer.

When you need an MRI, a colonoscopy, or an orthopedic consult, a direct care doctor can call around, compare outcomes, and send you to the independent imaging center charging $400 cash instead of the hospital outpatient department charging $2,800 against your deductible.

And if your current primary care doctor works for a hospital system, remember the 6 words tucked inside 42 CFR 411.354: the patient's preference overrides the contract. You always have the right to ask where else your referral can go. Better yet, hire a doctor whose contract only has your name on it.

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Nov 1 Is Open Enrollment Day and National DPC Day: Find the Doctor Before the Plan

On Nov 1, millions of people will open a website, sort plans by premium, squint at deductibles, and try to guess which network has their doctor in it.

The same day is National Direct Primary Care Day. That's not a coincidence. The date was picked because it falls right at the start of open enrollment, the one time of year most people are already thinking hard about their health care. The point of the day is a simple reminder: insurance isn't your only path to primary care.

Here's the order most of us do it in. Pick a plan. Then find out which doctors take it. Then find out how long the wait is. Then find out what the visit costs after the deductible.

Flip it.

Before you pick a plan, find a doctor.

A Saturday ear infection shows the difference fast. On a typical bronze plan chosen for the lowest monthly premium, a parent calls the pediatrician's office, hears the next opening is 3 weeks out, drives to urgent care, and waits for a bill that lands squarely on the deductible.

With a direct primary care doctor, that same Saturday starts with a text. The child gets seen that day or the next. There is no copay and no mystery bill in the mail a month later, because the monthly membership already covers the visit.

That's the model. You pay your doctor a flat monthly membership fee. No copays. No surprise bills. No insurance company deciding what kind of visit you're allowed to have. You get real time with your doctor, direct access by phone or text at many practices, and no pre-authorizations or networks between you and the physician who knows your history.

A membership doesn't replace catastrophic coverage. Most families pair direct care with a high-deductible plan or wrap-around coverage that sits in reserve for hospital stays, specialists, and true emergencies. Direct care handles the 90% of medicine that happens in an exam room or over the phone. The insurance policy stays where it belongs, guarding against the rare five-figure hospital bill.

And it's not a niche anymore. DPC Frontier's map lists more than 1,300 direct care practices across 48 states plus Washington, DC.

So this year, before you start comparing bronze and silver, do one thing first. Look up a direct care doctor near you. Then pick the plan that fits around that doctor, not the other way around.

If you're tired of 7-minute appointments and waiting days for a callback, Nov 1 is a good day to stop.

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