How to Start a Direct Primary Care Practice in 2026

On July 4, 2025, the Primary Care Enhancement Act was signed into law as part of the One Big Beautiful Bill Act. For the first time, patients can use Health Savings Account funds to pay for Direct Primary Care memberships — up to $150 per month for individuals and $300 for families. The “double-taxation” barrier that kept millions of HSA holders on the sidelines is gone.

The numbers tell the story. There are now over 2,800 DPC offices in the United States serving more than 1.4 million patients. The model has doubled its footprint since 2020. More than 7,200 employers offer DPC benefits, and employer-sponsored memberships account for 58% of all DPC patients — up 18% since 2022.

If you have been watching DPC from the sidelines, 2026 is the year the math changes in your favor. But starting a DPC practice still requires careful planning, honest financial projections, and a clear-eyed view of both the opportunity and the risks. This guide covers what you actually need to know.

Understand What You Are Getting Into

DPC is a membership-based model where patients pay a monthly fee directly to your practice in exchange for comprehensive primary care. No insurance billing. No coding. No prior authorizations. In return, you maintain a smaller panel — typically 400 to 600 patients instead of the 2,000 to 2,500 common in fee-for-service — and offer longer visits, same-day access, and direct communication.

The appeal is straightforward: you practice medicine instead of paperwork. A 2024 study in the Journal of General Internal Medicine found that DPC can yield upwards of $25,000 in annual cost savings over fee-for-service while delivering more personalized care.

But DPC is also a business, and you are responsible for building it from scratch. You will be the CEO, the marketer, the HR department, and the physician — at least in the beginning. The practices that fail almost always underestimate the business side, not the clinical side.

Form Your Legal Entity

Most states require physicians to operate under a Professional Corporation (PC) or Professional Limited Liability Company (PLLC) due to Corporate Practice of Medicine rules, which prohibit unlicensed individuals from owning or controlling a medical practice.

For a solo DPC practice, a PLLC is generally the simplest path. It offers pass-through taxation, fewer corporate formalities, and sufficient liability protection. Either a PC or PLLC can elect S-Corp taxation with the IRS to save on self-employment taxes — a meaningful savings once your revenue crosses roughly $80,000. Consult a CPA familiar with medical practices before making this election.

Some states require medical board approval before filing formation documents, so check your state’s requirements early.

Navigate State DPC Regulations

Over half of US states have enacted DPC-specific statutes that exempt DPC membership agreements from insurance regulation. But the details vary significantly.

Registration requirements. Some states, such as Washington, require DPC practices to register with the state insurance department. Others have no such requirement.
Membership agreement mandates. Many states require specific language and disclosures. Kansas, for example, requires boldface 10-point font disclosures in membership agreements.
No DPC-specific statute. If your state has not passed a DPC law, you operate under general contract law. This is workable but means less regulatory clarity.

The DPC Frontier maintains a state-by-state law tracker, and Patient Options publishes an updated 2026 guide to DPC laws by state. Both are worth reviewing before you engage an attorney — but they are not a substitute for one.

The Medicare Decision

This is the single most consequential compliance decision you will make, and it must be resolved before you see your first patient.

If you want to see Medicare beneficiaries in your DPC practice, you must formally opt out of Medicare by filing an affidavit with your Medicare Administrative Contractor. The opt-out lasts two years and auto-renews under MACRA unless you proactively cancel it. You must also have a signed private contract with each Medicare patient before any services are provided.

The penalties for getting this wrong are severe: up to $1,000 per violation, repayment of excess charges, and potential exclusion from Medicare. In 2026, the OIG has increased scrutiny of “hybrid” models where physicians attempt to partially opt out. Get a healthcare attorney involved in this decision.

Set Your Pricing

Membership pricing in DPC varies by market, patient demographics, and the scope of services you include. Current ranges look like this:

Segment	Monthly Range	Median
Adults	$65 - $150	$75 - $88
Children	$20 - $75	$35 - $50
Families	$150 - $300	$200 - $250

A common mistake is pricing too low in an attempt to be “affordable.” Your pricing needs to sustain the practice at realistic panel sizes. The average DPC practice has approximately 400 patients — not 600, not 1,000. Only 17% of DPC physicians reach a 600-patient panel.

Run your numbers at 350 to 400 patients, not at the optimistic end. At 400 patients paying $80 per month, your gross revenue is $384,000 per year. At $100 per month, it is $480,000. These are reasonable targets, but they take time to reach.

Additional Revenue Streams

Most successful DPC practices layer in supplemental revenue beyond membership fees:

Employer contracts. The fastest-growing channel. Small and mid-sized businesses facing 7-9% annual premium increases are actively seeking DPC partnerships, and employers report savings of up to 40% on healthcare costs.
In-office procedures. Joint injections, skin biopsies, IUD insertions, and similar primary care procedures can be included in membership or charged as add-ons.
In-office dispensing. Wholesale medications dispensed at cost or modest markup save patients money and generate modest revenue.
Lab services. Direct lab contracts allow you to offer labs at a fraction of retail pricing.

Build a Realistic Financial Plan

This is where honesty matters most. DPC practices do not fill overnight.

Startup Costs

The range is wide and depends on how lean you are willing to go.

Lean launch: $20,000 to $50,000. One documented example launched with $20,000 in initial capital and monthly operating expenses of approximately $3,000 (including $600 rent, $450 malpractice, $300 EHR, $500 medications, and $500 lab costs). This means a small rented space, minimal buildout, and doing most things yourself.

Moderate brick-and-mortar launch: $70,000 to $150,000. This includes office buildout, medical equipment ($10,000 to $50,000 for primary care), EHR implementation ($5,000 to $15,000), and working capital.

Working capital reserve: Plan for 12 to 15 months of combined personal income and operating expenses. This is the number most physicians underestimate, and insufficient runway is the most common reason DPC practices fail.

The First-Year Timeline

Be realistic about the ramp:

Months 1-3: 50 to 100 members. Friends, family, early believers.
Months 4-6: 150 to 250 members. Word of mouth starts compounding.
Months 7-12: 300 to 400 members. Approaching breakeven.
Breakeven: 6 to 18 months, depending on your overhead structure.
Full panel: 3 years on average to reach capacity.

Plan for approximately 5% monthly attrition. As one experienced DPC physician put it: “It will take you 1,000 patients to get to 600.” People move, change jobs, lose interest. Your acquisition engine needs to run continuously, not just at launch.

Build Your Technology Stack

Your EHR is the operational backbone of a DPC practice, but the requirements differ fundamentally from fee-for-service. You do not need complex billing and coding workflows. You do need membership management, integrated telehealth, patient communication, and e-prescribing.

What to Look For

DPC-native membership management. Automated recurring billing, employer invoicing, membership status tracking. If your EHR treats this as an afterthought, you will spend hours on manual workarounds.
E-prescribing. Surescripts-integrated, including Electronic Prescribing of Controlled Substances (EPCS) for Schedule II-V drugs.
Integrated telehealth. In 2026, patients expect to book virtual visits exactly like in-person appointments. A separate telehealth platform creates friction.
Mobile-friendly patient portal. Online intake, secure messaging, telehealth access, and payments. Mobile-first design is now a baseline expectation.
Lab integration. Direct ordering and results review within your workflow.
Patient communication. Secure messaging and SMS appointment reminders.

The Market

The DPC EHR market is fragmented. Atlas.md (starting at $149/month per provider) was built specifically for membership-based care and is widely used. Elation Health ($349/month) offers a clinical-first design with a dedicated DPC mode. Cerbo ($269/month) is popular with DPC and cash-pay practices for its flexibility. Hint Health focuses on the business layer — membership management and billing — and is often paired with a separate clinical EHR.

Newer entrants like Notive Health are building integrated platforms designed from the ground up for the DPC workflow, combining clinical documentation, membership management, e-prescribing, and patient communication in a single system. The trend across the market is toward consolidation: fewer tools, fewer logins, less friction.

Whatever you choose, prioritize a platform that treats DPC as a first-class use case rather than an add-on module bolted onto a fee-for-service system.

Acquire Your First Patients

A DPC practice operating outside the traditional referral ecosystem must generate its own demand. This is where many physicians feel the most uncomfortable — and where the most critical mistakes happen.

Pre-Launch

Do not rely on verbal commitments. A common DPC startup failure pattern: the physician surveys their community, gets enthusiastic responses, and launches expecting those people to sign up. When asked how many patients actually put money down before launch, the answer is often nobody. Interest is not commitment.
Build a pre-launch email list. Offer a landing page with a clear explanation of your model and a way for people to express real interest. Consider early-bird pricing for founding members.
Engage local employers early. Reach out to small businesses with 10 to 100 employees. These employers feel the pain of rising premiums most acutely and are often eager to learn about DPC.

Post-Launch

Community presence matters. Attend local events, speak at civic groups, partner with gyms and wellness businesses. “A DPC clinic without local trust is just another building with a sign.”
Online presence. A clear, professional website that explains what DPC is, what it costs, and how to sign up. Many patients have never heard of DPC and need education before they are ready to enroll.
Patient referrals. Your best marketing channel once you have a small base. Happy DPC patients are vocal advocates. Make it easy for them to refer friends and family.
Employer outreach. Systematically approach local businesses. DPCLife.org offers resources on structuring employer partnerships, and the DPC Alliance provides guidance on B2B revenue strategies.

Avoid the Common Mistakes

The DPC practices that struggle tend to share a few patterns:

Insufficient financial runway. The top killer. Without 12 to 15 months of reserves, financial stress drives physicians back to fee-for-service before the practice has time to mature.
Pricing too low. Underpricing to compete creates long-term sustainability problems. Run your model at 350 to 400 patients, not at a full panel you may never reach.
Neglecting the business side. It is increasingly common to see clinics open without a defined value proposition, a marketing budget, or a real understanding of DPC operations. Medicine is only half the job.
Ignoring Medicare compliance. Failing to properly opt out before seeing Medicare patients triggers severe penalties. This must be resolved before day one.
No marketing plan. Hoping patients will find you is not a strategy. Budget time and money for continuous patient acquisition.
Using non-compliant templates. A membership agreement that works in Texas may be non-compliant in New York or California. State-specific legal review is essential.
Not planning for attrition. Every practice loses patients. Plan for it in your financial model and keep your acquisition efforts running even after you feel “full.”

Know Your Resources

You do not have to figure this out alone. The DPC community is unusually collaborative.

Organizations

DPC Alliance — National organization offering malpractice insurance programs, advocacy, peer community, and practice resources.
DPC Frontier — State law tracking, membership agreement templates, events calendar, and academic article database.
AAFP Direct Primary Care — Educational resources, CME, and practice guidance from the American Academy of Family Physicians.
Startup DPC — Practical blog and guidance for launching practices.

Conferences (2026)

Hint Summit — Nashville, TN, April 8-11
California DPC Summit — Newport Beach, CA, June 5-7
DPC Summit 2026 — New Orleans, July 16-19 (hosted by AAFP, ACOFP, FMEC, and DPC Alliance; 400+ expected attendees)

Legal

Holt Law — DPC-specific legal practice publishing market reports and Medicare opt-out guidance.
McDermott Will and Emery — Publishes a comprehensive 50-state survey of DPC legal arrangements.
DPC Frontier Forms — Membership agreement and employer agreement templates.

Community

My DPC Story Podcast — Physician interviews about their DPC journeys. Highly recommended for hearing real experiences.
DPC News — News aggregation and opinion for the DPC community.

The Bottom Line

Starting a DPC practice in 2026 is more viable than it has ever been. The HSA legislation removes a major financial barrier for patients, employer adoption is accelerating, and the infrastructure — legal templates, EHR platforms, community knowledge — is more mature than even two years ago.

But viability is not the same as ease. You need adequate financial runway, honest projections, a real marketing plan, and the willingness to learn business operations alongside clinical care. The physicians who succeed in DPC are the ones who respect the business as much as the medicine.

The model is sound. The timing is right. The question is whether you are ready to build it.