Abstract
Background:
Direct Primary Care (DPC) offers an alternative healthcare delivery model with potential benefits for patient-centered care. However, concerns remain about its equity and accessibility, particularly in urban settings. This study examines the utilization patterns and patient engagement within a DPC clinic in Houston, Texas, and whether subscription duration impacts patient-provider interactions in an urban healthcare environment.
Methods:
Deidentified data from a Houston-based DPC clinic (January 2023-January 2024) were analyzed. Patient demographics, subscription details, and interaction data (including in-person appointments and audio-visual calls) were collected. Descriptive statistics summarized utilization patterns, while logistic regression models assessed relationships between demographic factors and DPC utilization.
Results:
The sample included 71% Non-Hispanic Black patients, 21% Non-Hispanic White, and 77% females. Most patients resided in urban areas (79%) and paid over $125 monthly (44%). Subscription duration positively correlated with engagement: patients subscribed for ≥21 months had higher yearly averages for chart interactions and appointments compared to those who subscribed for ≤5 months. Regression analysis revealed significant dose-response increases in patient engagement among those with longer subscription durations across all interaction types. No other demographic characteristics were significant predictors of DPC utilization.
Conclusion:
Subscription duration strongly influences DPC utilization, suggesting sustained enrollment fosters deeper patient engagement and more frequent provider interactions. While DPC may enhance patient-provider relationships, cost and urban-centric accessibility may pose barriers to equity.
Keywords: primary health care, access to primary care, health equity, health disparities, facilities and services utilization, concierge medicine
Introduction
While accessible, robust primary care is widely recognized as essential in improving patient outcomes and strengthening the healthcare system, 1 traditional delivery models often present significant barriers to achieving these goals. Direct Primary Care (DPC), a relatively new primary care practice model, has risen in response to these challenges. DPCs are a membership-based model where patients pay a flat, recurring monthly fee to receive unlimited comprehensive primary services, including regular checkups, routine care, and preventative care. 2 Aiming to ‘uncouple’ primary care from health insurers, DPCs allow patients to alleviate previous pressures and limitations associated with traditional fee-for-service (FFS) and insurance models. 3 As a bottom-up, physician-driven approach to healthcare, 4 DPCs aim to increase transparency and to satisfy the quadruple aim of lower cost and better patient experience, health outcomes, and clinician experience. 5
In the view of many, including the American Academy of Family Physicians, DPC’s 2-party structural change can contribute to bending the cost curve while also eliminating barriers to direct physician access associated with insurance-centered healthcare delivery models. Early work suggests that DPC increases clinician time with patients, 6 decreases physician burn-out, 7 while reducing overhead costs 3 and administrative burden. Another suggested benefit of the DPC model is that clinicians can introduce new services to their patients without prior authorization from insurance companies. In the past 6 years, DPCs have experienced exponential growth among clinical practices, exceeding 1000% 8 with over 2000 practices in the United States across 48 states. 9 This widespread growth was significantly seen following the COVID-19 pandemic, with HintOS, a management system for DPC practices, expanding its presence from 20 states in 2019 to 40 states by 2021. 10 The global direct primary care market generated $55.8 billion in 2022 and is predicted to generate $82.5 billion by 2032. 11
Though it offers a variety of potential benefits, gaps remain in our understanding of utilization patterns in DPC practices. For example, some have suggested that DPC may exacerbate already existing healthcare disparities by decreasing access to those who are unable to afford the periodic fees. 12 The DPC concept also raises the questions of whether DPC is the preferred healthcare model for patients themselves and whether it promotes patient-clinician interactions. Working with a DPC clinic in the Houston area, this study seeks to characterize DPC in a large urban setting and examine patient interaction patterns with DPC providers. This work contributes to the ongoing discourse on DPC by exploring the role of subscription duration in patient engagement and assessing whether DPC fosters the continuity necessary for effective patient-clinician relationships in an urban healthcare environment.
Methods
This is a retrospective cohort study. Deidentified data were obtained from a DPC clinic in the greater Houston area that emphasizes holistic patient care. The data encompassed demographic characteristics and appointment information for patients seen between January 1, 2023, and January 31, 2024. Data included demographic characteristics (patient age, biological sex, and race), appointment history (length of time in months in DPC and visit month/year), frequency of patient-clinic contacts (emails, telemedicine, chart interactions, and SMS), DPC administrative details (subscription cost and subscription duration), and patient geographic residence (urban vs suburban vs rural). Descriptive statistics (mean, standard deviation, frequency, and percentage) were used to summarize the data. Two separate linear regression models examined adjusted relationships between demographic characteristics and frequency of patient-clinic interactions, as depicted by the following independent outcomes of interest: (1) chart interactions defined as interactions initiated by patients and/or clinicians, and (2) appointments made: defined as in-person clinical consults or audio-visual calls. These counts were normalized by adjusting observed use to a 12-month period. For subscriptions shorter or longer than 1 year, the total number of uses was divided by the number of active months and multiplied by 12 to yield an annualized utilization rate.
Due to the deidentified nature of the data, the requirements for informed consent and IRB approval were waived by an independent institutional review board affiliated with the authors’ institution.
Results
Table 1 shows the summary characteristics of the patients at the DPC clinic. Approximately 21% of the sample were aged 19 years or under, 27% were 20 to 39 years, 38% were 40 to 64 years, and 14% were 65 years or older. The sample comprised 77% females, and racial and ethnic subgroups included 21% Non-Hispanic White, 71% Non-Hispanic Black, and 8% Other. For monthly subscription costs, 13% of patients paid $50 or less, 4% paid between $51 and $100, 30% paid $110, 9% paid $135, and 44% paid more than $125 monthly. Regarding DPC subscription duration, 25% of patients had been subscribed for 0 to 5 months, 25% for 6 to 12 months, 25% for 13 to 20 months, and 25% for over 21 months. Although none of the patients reported living in a rural area, 21% resided in suburban areas and 79% in urban areas.
Table 1.
Unique DPC Patient Characteristics at Baseline (n = 112).
| Variable | Total |
|---|---|
| N (%) | |
| Age | |
| ≤19 | 23 (20.5) |
| 20-39 | 30 (26.8) |
| 40-64 | 43 (38.4) |
| >65 | 16 (14.3) |
| Sex | |
| Female | 86 (76.8) |
| Male | 26 (23.2) |
| Race/ethnicity | |
| Non-Hispanic White | 23 (20.5) |
| Non-Hispanic Black | 79 (70.5) |
| Other | 10 (9.0) |
| Monthly subscription cost | |
| ≤$50 | 15 (13.4) |
| $51-$100 | 4 (3.6) |
| $110 | 33 (29.5) |
| $125 | 10 (8.9) |
| >$125 | 50 (44.6) |
| Subscription duration (months) | |
| 0-5 | 27 (25.6) |
| 6-12 | 26 (24.8) |
| 13-20 | 26 (24.8) |
| ≥21 | 26 (24.8) |
| Patient geographic residence | |
| Rural | 0 (0.00) |
| Suburban | 24 (21.4) |
| Urban | 88 (78.5) |
Average Count of Chart Interactions and Appointments Made Among DPC Patients
Table 2 shows the average count of chart interactions and appointments made (including in-person and audio-visual calls) across a 12-month period. Patients under a DPC clinician had, on average, 13 chart interactions and 7 appointments annually. Patients aged 19 years or under had a yearly average of 9 chart interactions and 5 appointments; patients aged 20 to 39 years had a yearly average of 11 chart interactions and 6 appointments; patients aged 40 to 64 years had a yearly average of 15 chart interactions and 8 appointments; patients aged 64 years or older had a yearly average of 19 chart interactions and 8 appointments. Female patients had a yearly average of 11 chart interactions and 6 appointments, while male patients had a yearly average of 14 chart interactions and 7 appointments.
Table 2.
Average Count of Chart Interactions and Appointments Made among DPC Patients (n = 112).
| Variable | Chart interactions | Appointments made (in-person and audio-visual calls) |
|---|---|---|
| Overall | 13.29 | 6.89 |
| Age | ||
| ≤19 | 9.30 | 5.10 |
| 20-39 | 10.96 | 5.96 |
| 40-64 | 14.71 | 7.80 |
| >65 | 18.75 | 8.38 |
| Sex | ||
| Female | 11.20 | 5.88 |
| Male | 13.95 | 7.20 |
| Race/Ethnicity | ||
| Non-Hispanic White | 15.23 | 7.76 |
| Non-Hispanic Black | 13.00 | 6.76 |
| Other | 11.00 | 5.75 |
| Monthly subscription cost | ||
| ≤$50 | 10.47 | 5.60 |
| $51-$100 | 7.50 | 5.00 |
| $110 | 15.88 | 8.19 |
| $125 | 20.50 | 7.60 |
| >$125 | 11.11 | 6.33 |
| Subscription duration (months) | ||
| 0-5 | 4.89 | 2.78 |
| 6-12 | 12.42 | 6.81 |
| 13-20 | 16.23 | 8.42 |
| ≥21 | 19.96 | 9.69 |
| Patient geographic residence | ||
| Suburban | 13.99 | 7.17 |
| Urban | 10.83 | 5.87 |
Patients identifying as Non-Hispanic White had a yearly average of 15 chart interactions and 8 appointments; those identifying as Non-Hispanic Black had a yearly average of 13 chart interactions and 7 appointments; those identifying as other had a yearly average of 11 chart interactions and 6 appointments. Regarding monthly subscription costs, patients paying $50 or less had a yearly average of 11 chart interactions and 6 appointments; those paying between $51 and $100 had a yearly average of 8 chart interactions and 5 appointments; those paying $110 had a yearly average of 16 chart interactions and 8 appointments; those paying $125 had a yearly average of 21 chart interactions and 8 appointments; and those paying more than $125 had a yearly average of 11 chart interactions and 6 appointments. For DPC subscription length, patients with subscriptions to a DPC clinician for 5 months or less, had a yearly average of 5 chart interactions and 3 appointments; patients with subscriptions between 6 and 12 months had a yearly average of 12 chart interactions and 7 appointments; patients with subscriptions between 13 and 20 months had a yearly average of 16 chart interactions and 8 appointments; patients with subscriptions for 21 months or longer had a yearly average of 20 chart interactions and 10 appointments. With regards to patient geographic residence, patients living in suburban areas had a yearly average of 14 chart interactions and 7 appointments, while patients living in urban areas had a yearly average of 11 chart interactions and 6 appointments.
Multivariate Analysis
Table 3 shows the regression results of the multivariate analysis conducted for chart interactions, and appointments made across a 12-month period, respectively. Compared to those enrolled for 0 to 5 months, those enrolled for longer periods had significantly higher chart interactions (6-12 months β = 7.41, P < .001; 13-20 months β = 94 8.35, P < .001; ≥21 months β = 12.70, P < .001). There was also a similar dose-response increase for appointments made (6-12 months β = 3.93, P < .001; 13-20 months β = 5.07, P < .001; ≥21 months β = 6.27, P < .001). No other patient characteristics were found to have a significant influence on DPC utilization.
Table 3.
Regression Model of Yearly Chart Interactions and Appointments Made among DPC Patients (n= 112).
| Variable | Chart interactions |
Appointments made (in-person and audio-visual calls) |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Coef. | 95% CI | P | Coef. | 95% CI | P | |||||
| Age | ||||||||||
| ≤19 | Ref | Ref | ||||||||
| 20-39 | 2.04 | −4.28 | — | 8.36 | 0.52 | 1.27 | −1.91 | — | 4.45 | 0.43 |
| 40-64 | 4.25 | −1.58 | — | 10.09 | 0.15 | 1.82 | −1.11 | — | 4.77 | 0.22 |
| ≥65 | 4.26 | −2.19 | — | 10.70 | 0.19 | 1.79 | −1.45 | — | 5.04 | 0.28 |
| Sex | ||||||||||
| Female | Ref. | Ref. | ||||||||
| Male | 2.24 | −0.65 | — | 5.13 | 0.13 | 0.03 | −1.43 | — | 1.48 | 0.97 |
| Race/ethnicity | ||||||||||
| Non-Hispanic White | Ref. | Ref. | ||||||||
| Non-Hispanic Black | −0.72 | −3.75 | — | 2.31 | 0.64 | −0.33 | −1.85 | — | 1.20 | 0.67 |
| Other | −1.89 | −7.02 | — | 3.24 | 0.47 | −0.60 | −3.18 | — | 1.98 | 0.65 |
| Monthly subscription cost | ||||||||||
| ≤$50 | Ref. | Ref. | ||||||||
| $51-$100 | −2.32 | −13.37 | — | 8.72 | 0.68 | 0.63 | −4.93 | — | 6.18 | 0.82 |
| $110 | 1.56 | −5.40 | — | 8.51 | 0.66 | 0.57 | −2.93 | — | 4.07 | 0.75 |
| $125 | 0.27 | −7.68 | — | 8.22 | 0.95 | 0.69 | −3.31 | — | 4.69 | 0.73 |
| >$125 | −0.38 | −6.83 | — | 6.07 | 0.91 | 0.55 | −2.70 | — | 3.80 | 0.74 |
| Subscription duration (months) | ||||||||||
| 0-5 | Ref. | Ref. | ||||||||
| 6-12 | 7.41 | 3.79 | — | 11.04 | <0.001 | 3.93 | 2.10 | — | 5.75 | <0.001 |
| 13-20 | 8.35 | 4.50 | — | 12.20 | <0.001 | 5.07 | 3.13 | — | 7.01 | <0.001 |
| ≥21 | 12.70 | 8.82 | — | 16.58 | <0.001 | 6.27 | 4.31 | — | 8.22 | <0.001 |
| Patient geographic residence | ||||||||||
| Suburban | Ref. | Ref. | ||||||||
| Urban | −2.93 | −5.98 | — | 0.12 | 0.06 | −1.14 | −2.68 | — | 0.40 | 0.14 |
Discussion
In this study examining chart interactions and appointments made by DPC patients, our results suggest this novel setting to be characterized by high utilization and consistent use across patient characteristics. Importantly, our findings demonstrate high utilization compared to traditional FFS clinics reported in the literature. For example, while the average annual visit rate was 1.5 visits per person in 2015, 13 and varied between 0.7 and 2.5 telemedicine visits in Medicare settings, 14 DPC patients exhibited an average of 6.89 in-person or audio-visual appointments per year. While limited research has examined patient interactions in DPC settings, these findings suggest that DPCs may facilitate more patient interactions. We posit that the subscription-based nature of the DPC model allows patients to seek care for even minor health concerns, enabling proactive health management. This high utilization reflects DPC’s ease of care continuity, a principle that has been linked to higher satisfaction rates, cost-effective care, and better healthcare outcomes. 15
The finding of a dose-response increase in DPC utilization as subscription duration increased is note-worthy. Compared to the current literature, which has long reported disparities in chart interactions, telemedicine, and in-person appointments by age, sex, and race/ethnicity,16,17 our results found none of these demographic characteristics to be associated with DPC utilization. These results potentially tie the DPC model with equity, potentially through building and maintaining the patient-clinician relationship 18 although research is needed in this area, considering our small sample size.
This study has several limitations that should be considered when interpreting the findings. First, the data are derived from a single DPC organization, which may limit generalizability to other DPC practices with varying patient demographics, geographic locations, or operational models. The single-site design and lack of a comparator group (i.e. non-DPC practice) makes it difficult to fully isolate the effects of the DPC model and may restrict generalizability. Second, we relied on retrospective data, which inherently risks missing contextual information about patient behaviors or external factors influencing utilization. Additionally, the observational nature of this research limits our ability to establish causation between the subscription-based DPC model and the observed high utilization. Future studies should address these limitations by incorporating prospective designs, diverse DPC settings, and direct patient outcome comparisons to explore the impact of this innovative care model further.
In conclusion, this study highlights the distinct advantages of the DPC model in fostering high utilization of primary care. Notably, the absence of disparities in utilization across age, sex, and race/ethnicity potentially positions DPC as a model that advances health equity; however, future studies are needed to examine this relationship. Furthermore, the dose-response relationship between subscription duration and utilization emphasizes the importance of trust and ongoing communication in strengthening patient-clinician relationships. These results provide insights into the DPC model’s potential to transform healthcare delivery, emphasizing its value in creating a more accessible and patient-centered care environment.
Acknowledgments
We have no additional acknowledgements to declare.
Footnotes
ORCID iD: Omolola E. Adepoju 
https://orcid.org/0000-0002-5585-7146
Author Contributions: AA was responsible for conceptualization and data curation. PD was responsible for data cleaning formal analysis, and writing the original draft. OAE was responsible for conceptualization, formal analysis, writing, and editing the manuscript. All authors participated in reviewing and approving the final draft.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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