I play Go. Not chess. Not checkers. Go: the ancient strategy game where the objective is not to capture pieces but to claim territory. In chess, you attack. In checkers, you jump. In Go, you place. Each stone lands quietly. Each position builds on the last. The opponent is still arguing about three moves ago while the board is already decided. The board has been built one placement at a time. For the past several months, analysis on direct care models and employer-aligned primary care has been accumulating here (see the prior piece on employer-aligned DPC and physician autonomy), each piece a different angle on the same territory. The data behind it is cited.

None of that data has been disputed. What arrived instead was not a debate. It was a pattern. Attack the credential. Question the motive. Announce the rebuttal. Drop the article in the comment thread. Repeat. The Bureau of Labor Statistics figures, the KFF survey data, the AMA ownership benchmarks, and the Milbank Scorecard were never touched. A credential attack is not a stone. It does not move the territory. Some of the substantive arguments circulating in the market, however, are worth examining on the merits.

The right question points in the wrong direction

The question of why physicians left traditional medicine is the right question. The answer is the slow accumulation of administrative weight, every metric, every productivity benchmark, every prior authorization, that arrived not as a hostile takeover but as a series of reasonable-sounding negotiations. The guardrails became the cage. That diagnosis is correct. It is also an argument for what comes next, not an argument against it. Physicians left because institutional employment extracted their autonomy incrementally. The question now is what prevents that from happening again.

According to the AMA’s 2024 Physician Practice Benchmark Survey, only 35.4 percent of physicians held an ownership stake in their practice in 2024, down from 53.2 percent in 2012 and from approximately 76 percent in the early 1980s. A PAI-Avalere analysis found that 77.6 percent of all U.S. physicians are now employed by hospitals, health systems, or corporate entities. The trend is not slowing. The employer channel, structured on physician terms, is one of the few available mechanisms to reverse it, not by re-entering the same institutional structures, but by negotiating outside them.

The analogy that assumes the market already works

The grocery store analogy is a clean argument. A grocery store does not need to partner with local employers so workers can afford food. It does not need a TPA between the produce section and the customer. The store sets its prices. The customer decides. It is also describing a market that American health care dismantled decades ago.

A DPC practice does not operate in a functioning consumer market. It operates in a market where 154 million Americans access care through employer-sponsored insurance, where the KFF 2025 Employer Health Benefits Survey shows average family premiums have reached $26,993 per year, and where the BLS 2024 Consumer Expenditure Survey shows median household expenditures running $78,535 against pre-tax income of $104,207. A household in that position is not making a free consumer choice. They are deciding whether to add a $100 to $150 monthly DPC membership on top of a catastrophic insurance premium that already consumes a significant share of their disposable income. The grocery store does not have that problem because food is not intermediated by a third-party payer that pre-negotiates what the store can charge before the customer walks in. The reason DPC needs a structural alternative to pure retail demand is precisely because the system has already eliminated the functioning market the analogy assumes. Pointing to that market as the solution does not explain how to reach it from here.

Both costs are broken. That is the argument, not the objection

The $27,000 employer family premium warrants the same scrutiny as the $150 monthly DPC membership. The $150 membership is not the access problem. It is one of the solutions. The $27,000 annual premium is the problem. That is precisely the argument the employer-aligned case has been making.

The employer channel as currently structured routes $27,000 per year per family through insurers who set the terms, design the network, and capture the margin. The case for physician-led employer contracting is not that physicians should accept that structure. It is that the employer relationship can be used to restructure it. When an employer contracts directly with a DPC or direct care practice as a line item in the benefits package, the membership cost is absorbed at the employer level. The household no longer faces the dual burden of the insurance premium and the membership fee simultaneously. The employer gains direct leverage over primary care access and total spend. The physician captures a recurring contract outside insurance billing architecture. The insurer is partially disintermediated.

That is not capitulation to the broken system. That is using the employer’s existing economic position to route around it. The $27,000 premium and the $150 membership are both symptoms of the same structural failure. The employer channel, structured correctly, addresses both.

The questions on the board were already there

Four questions have been central to this analysis from the beginning: Which partnership structures preserve physician autonomy and panel discipline? Which contracting models maintain price transparency? Which employer arrangements expand access without recreating administrative burden? Where does new infrastructure add clinical value versus simply adding margin layers? Those questions did not originate as objections. They are the analytical framework this work has been building toward. The fact that they are now being raised as challenges to the employer-aligned argument is worth noting, because the framing assumes the questions point toward retail DPC as the answer.

The case for pure retail DPC is straightforward: no employer, no intermediary, patient pays physician directly. The physician sets panel size, sets price, and controls the relationship. That model works, and it deserves credit for what it has built. The market, however, has already moved underneath it. According to the Hint Health 2025 Employer Trends in Direct Primary Care report, compiled from data across 2,400 DPC clinicians, 7,200 employer sponsors, and 1.2 million members, 58 percent of all DPC memberships in 2024 were employer-sponsored, up 18 percent since 2022. A third of employer-DPC memberships now flow through networks rather than independent practices. The retail model is actively becoming majority employer-sponsored. The question was never whether retail DPC can survive. The question is whether independent physicians control what is replacing it.

The practices already working inside employer-aligned structures are building the answers contract by contract. Those answers require operational context that no op-ed can provide. What can be said here is that the questions are the right ones, and that asking them is exactly what physicians entering this space should be doing before they sign anything.

The physician is the product. The question is who structures the deal

Primary care physicians are the front door of a $5.3 trillion system. Every referral is a capital routing decision. Every panel is a revenue stream that flows somewhere. The physician carries the clinical relationship. The current system captures the economic return.

The Milbank 2026 Primary Care Scorecard shows national primary care spending dropped to 4.5 percent of total health expenditure in 2023. OECD nations average approximately 8 percent. The U.S. spent $5.3 trillion on health care in 2024, and less than five cents of every dollar reached a primary care physician. That gap did not accumulate because physicians lacked clinical skill. It accumulated because physicians accepted influence as a substitute for economic ownership.

The concerns about intermediary extraction are legitimate. They are also an argument for physician-controlled contract structure, not an argument against the employer channel. Every platform fee, every TPA arrangement, every navigation vendor taking a cut exists because a physician did not negotiate the terms before signing. The protection is not avoidance. It is the contract. Physicians who understand that are already building it. The employer channel is not the enemy of DPC’s founding principles. Unexamined participation in it is. The difference between those two things is the contract.

This essay is cited in the KevinMD record on physicians and administrators.

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.