Primary care innovation has always been framed around access, autonomy, burnout, and patient experience. Direct primary care (DPC) in particular is often positioned as a solution for physicians exhausted by fee-for-service complexity and for patients who want a more personal relationship with their doctor.

This article focuses on how the broader economic landscape has shifted in ways that directly affect DPC, especially in light of the rapidly evolving national discussion around HSA eligibility and DPC affordability. Before examining how employers and institutions structure sustainable models for lower-income populations, it’s important to establish that economic context.

This is not a question of clinical philosophy. It is a question of affordability, elasticity, and long-term sustainability in a middle-class environment that has fundamentally changed.

The middle class is under pressure, and retail DPC feels it first

Retail DPC assumes that households can reliably pay about $70 to $150 per month per adult for primary care access. A decade ago, that assumption was more secure. But in 2025, inflation, wage stagnation, and employment instability have reshaped household economics in ways that directly affect membership-based care.

Recent CPI data shows cumulative inflation of approximately 18.2 percent over the past four years, according to the U.S. Bureau of Labor Statistics. Consumers are canceling subscriptions across industries as discretionary income tightens, and behavioral economics research consistently shows that preventive health care is categorized as a discretionary expense unless triggered by an acute need.

This creates a core problem for retail DPC: DPC is a subscription model operating in an era of subscription fatigue.

Households facing rising rent or mortgage costs, higher insurance premiums, more expensive groceries, and the growing cost of childcare and transportation are making financial decisions month to month. Even a modest membership becomes elastic when priorities shift. The value of the care may remain constant, but the household tolerance for recurring discretionary costs does not.

Retail DPC’s biggest challenge is not marketing or patient education. It is affordability within modern economic conditions.

Elasticity and churn: the fragile core of consumer-paid DPC

Retail DPC clinics depend on predictable, recurring membership revenue. But households under strain introduce volatility:

• Higher churn
• Pauses in membership
• Skipped payments
• Seasonal cancellations
• Unpredictable cash flow

Although national churn statistics are not consistently reported, many DPC practices serving middle-income communities report turnover related to job changes, insurance premium increases, or household budget tightening.

This does not mean retail DPC cannot work. It means it cannot scale predictably and cannot sustain every market segment. Retail DPC will continue to thrive in higher-income communities where households have the discretionary bandwidth to maintain a monthly health care subscription.

But for middle-income markets under prolonged financial pressure, the economic reality is different.

Employer-sponsored DPC is an entirely different economic model

It is often claimed that hospital systems cannot operate DPC because it conflicts with fee-for-service incentives. But this is not accurate. Systems cannot scale retail DPC, but they can and do scale employer-sponsored DPC because the economics are entirely different.

CHI Health is a clear example, offering employer-integrated primary care services that reflect the DPC model in structure and access. These clinics succeed because the employer pays for the membership, shifting affordability from the household to the organization.

Employer-sponsored DPC succeeds because:

• The employer pays, not the consumer.
• Churn stabilizes because turnover, not household budget strain, becomes the driver.
• Reporting and analytics are possible because systems already have infrastructure.
• Revenue becomes predictable, supporting staffing and quality programs.
• The model aligns with population health strategies already in use across systems.

Employer-integrated DPC is not limited to health systems. National organizations such as Everside Health and Marathon Health operate DPC-inspired primary care models for employers across the country. These examples demonstrate that DPC, when aligned with the right economic engine, can succeed at scale.

Employer DPC is not retail DPC at scale. It is a structurally different model.

Why physicians often confuse the two

Many conversations about DPC treat it as a monolithic model. In reality, retail DPC and employer-sponsored DPC have fundamentally different economic assumptions.

Retail DPC is sensitive to:

• Household income
• Inflation
• Discretionary spending patterns
• Membership elasticity

Employer DPC is sensitive to:

• Benefit design
• Workforce turnover
• Contract structure
• Reporting expectations

Retail success requires households to choose to spend. Employer success requires HR leaders to choose to invest. One is funded by personal discretionary income. The other is funded by organizational strategy.

This distinction matters more than many discussions acknowledge.

The path forward: matching the model to the market

DPC is not broken. But the assumption that one version of it works everywhere is flawed. Here is a more accurate framework.

Retail DPC works when:

• Household income is stable
• Out-of-pocket tolerance is high
• Inflation is low
• The market has a strong small-business base
• Panels can stay narrow
• The population is young to middle-aged
• Discretionary income is predictable

Employer-sponsored DPC works when:

• The employer subsidizes or covers memberships
• Population health reporting is required
• The workforce is large enough to stabilize revenue
• The employer prioritizes predictable access and reduced absenteeism

The point is not to predict the failure of retail DPC. The point is to recognize that retail DPC is highly dependent on the economic profile of the community it serves. Employer-sponsored models provide stability because their revenue is not tied to household volatility.

Conclusion: DPC’s future depends on economics, not ideology

Primary care innovation will continue to evolve. DPC offers real strengths: continuity, easier access, and deeper physician-patient relationships.

But sustainability will come from understanding:

• Household affordability
• Income elasticity
• Employer demand
• Cost structure
• Segmentation across markets
• Population health incentives

Retail DPC will maintain a role, particularly in higher-income communities. But employer-sponsored models offer stability that retail DPC cannot always achieve in today’s economic environment. Understanding these distinctions is essential if DPC is to evolve into a durable part of primary care rather than remain an ideological position.

Dana Y. Lujan is a health care strategist and operator with more than twenty years of experience across payers, providers, and health systems. She is the founder of Wellthlinks, a consulting firm that helps employers and providers redesign care models through concierge and direct primary care, and author of The CEO Physician: Strategic Blueprint for Independent Medicine. Dana has led multi-state network development, payer contracting, financial modeling, and compliance initiatives that strengthen provider sustainability and employer value. She previously served as president of the Nevada chapter of HFMA and is pursuing a JD to expand her expertise in health care law and compliance. She has been featured in Authority Magazine and publishes on KevinMD, MedCity News, and  Medium, where she writes on health care innovation, direct primary care, concierge medicine, employer contracting, and compliance. She has forthcoming BenefitsPRO. Additional professional updates can be found on LinkedIn and Instagram.