Direct primary care membership pricing: how to set it

A direct primary care practice replaces a stack of insurance claims with one monthly membership fee. That makes the price of the membership the single most important number in the practice, and the way it is billed a close second. This guide is about both, and only about billing: what tiers to offer, how to price a family, monthly against yearly, charging for things outside the plan, and what to do when a card fails. It is not medical, legal or regulatory advice. Rules about what a membership may include, and how it may be sold, differ by state and country, so check what applies to your practice before you publish a price.

Start from the panel, not from a competitor's price list

Every practice has a rough number of members it can look after well and a monthly amount it needs to take in. Put the two side by side before anything else. Say a practice plans for 600 members and needs $42,000 a month to cover staff, rent and the physician's pay. That is an average of $70 per member per month.

The average is not the price. The mix of adults, children and seniors on the panel decides what each tier has to be for the average to land where it needs to.

Adult, child and senior tiers

Three tiers cover most practices. As an example:

Tier	Monthly
Adult	$79
Child	$29
Senior	$69

Check the mix against the target. If the 600 members are 400 adults, 120 children and 80 seniors, the practice takes in $31,600 + $3,480 + $5,520 = $40,600 a month, an average of about $67.67. That is $1,400 short of the $42,000 target, so either a price moves or the panel needs more members. Doing this sum with your own panel is the most useful hour you will spend on pricing.

Two common rules keep the tiers fair:

• Children join with an adult. The child price is low because a parent is on the plan. Offering it on its own invites the whole family to sign up children only.
• Age tiers change on a date. Decide when a child becomes an adult on the price list (a birthday, or the next renewal) and write it down, so the price change is expected.

Family caps

Large families push the monthly bill up fast. Two adults and three children at the prices above come to $158 + $87 = $245 a month. Many practices cap it. One simple version: the third and later children are free. The same family then pays $158 + $58 = $216, the same as a family with two children.

Show the cap on the invoice as its own discount line ("Third child included, minus $29.00") rather than as an unexplained lower price. The family sees what they are getting, and when a child ages out of the child tier the change in the bill explains itself.

Bill the whole family on one invoice to whoever pays. Four separate charges on a statement every month are four chances for a bank to query one of them.

Monthly or yearly

Offer both. Monthly is the easy start; yearly brings cash forward and keeps members through the months they do not visit. A common discount is two months free:

• Adult: $79 × 10 = $790 a year, against $948 paid monthly.
• The family above: $216 × 10 = $2,160 a year, against $2,592.

Decide before you sell a yearly plan what happens when a member leaves partway through. The two honest choices are a refund for the unused months, prorated to the day, or no refund with the membership running to the end of the year. Either can be right. Stating it at signup is what matters, because it is the first question a member asks when they move away.

Enrollment fees

Some practices add a one off enrollment fee to cover the first long appointment and setting up the record. If you charge one, bill it as its own line on the first invoice, separate from the membership, so the monthly price stays the monthly price. Waiving it for a limited period is a simpler promotion than discounting the membership itself.

Visits and extras outside the plan

No membership covers everything. Labs, certain procedures, products and visits outside what the plan includes need a price too.

• Publish the price list. A member who knows a lab panel is $45 before they agree to it does not dispute the charge.
• Charge the card on file the same day, with the invoice emailed, so the charge on their statement matches a piece of paper they already have.
• Keep clinical details out of billing. Name the line "Lab panel", not the test or the reason for it. Invoices are read by whoever pays the bill, which in a family is not always the patient.

Adding someone partway through a month

A newborn or a new partner joining in the middle of the month should pay only for the days left. A child joining with 15 days left in a 30 day month pays $29 × 15 / 30 = $14.50 on the first invoice, then the full $29 from the next month on.

Failed payments

A membership practice lives on recurring payments, so a failed card is not a rare event. Cards expire, get replaced and get declined for reasons that clear in a few days. A calm process handles most of it:

1. An expired card gets a note before the charge, with a link to update it.
2. A declined card is retried a few days later, when a temporary problem has often cleared.
3. The member gets a short note with a link to fix it themselves, so the front desk does not make payment calls.
4. A grace period is decided in advance. Choose how long a membership stays active while a payment is outstanding, and what happens at the end of it. Your obligations to patients are not a billing question; set the billing rule with them in mind.

Track how many failed payments were paid by the end of the month. Our guide to dunning best practices covers retry timing and the emails in more detail.

The short version

• Work back from the panel you can look after and the amount you need.
• Adult, child and senior tiers, children with an adult.
• A family cap shown as a discount line, one invoice per family.
• Monthly and yearly, with the leaving policy stated up front.
• A published price list for everything outside the plan, charged the same day, with nothing clinical on the invoice.
• A failed payment process that runs without the front desk.

yRecurring handles the billing side of a care membership: adult, child and senior plans monthly or yearly, a family on one invoice, visits and extras charged to the card on file, and failed cards fixed from a link. It holds names, plans and payments, never clinical notes. See it in membership billing for clinics and care practices.