Listen to the podcast here: What Causes Attrition in Pediatric DPC?
Episode Summary: In this episode of the DPC Pediatricians Podcast, Phil and Marina tackle a question every Direct Primary Care (DPC) pediatrician eventually faces: why do patients leave—and how often does it really happen?
Drawing on five years of real-world experience, they unpack the truth behind patient attrition in a membership-based model. While DPC is known for its accessibility, strong relationships, and high-quality care, no practice is immune to turnover. But the reasons patients leave may surprise you—and they’re not always what you’d expect.
From families relocating or experiencing financial changes, to shifts in expectations or misunderstandings about the DPC model, Phil and Marina break down the most common causes of attrition. They also explore a critical mindset shift: not all attrition is a failure. In many cases, it’s a natural and even healthy part of running a sustainable practice.
The conversation goes deeper into how pediatricians can:
- Set clear expectations from the start
- Build stronger, longer-lasting relationships with families
- Identify preventable vs. unavoidable attrition
- Use patient departures as opportunities for growth and refinement
If you’ve ever worried about losing patients—or wondered what attrition really looks like in a thriving DPC practice—this episode offers both reassurance and practical insight.
Whether you’re new to DPC or years into your journey, this discussion will challenge your assumptions and help you build a more resilient, patient-centered practice.
Welcome to DPC Pediatrician. We’re Dr. Phil Boucher and Dr. Marina Capella, two DPC pediatricians who are on a mission to share our love of direct primary care with you.
Welcome everyone to another episode of the DPC Pediatricians Podcast. Today, Phil and I are going to be talking about attrition in pediatric DPC. It’s one of the questions that kind of circulates around in the DPC atmosphere of, okay, I work so hard to get these patients to attract them to my practice.
And then there’s always a risk of people leaving. And when they leave, why do they leave? And how common is it for people to leave your practice after they sign up for this membership model and experience the great quality and the great accessibility and everything that DPC offers?
So Phil and I have been in DPC practice now for about five years. Phil, when you think about the patients who have left your membership, what are the top reasons that you can think of for why that happens.
Yeah. So it’s interesting that this topic, I was looking at the topic list today and just this morning, a mom had texted and said, is it possible for us to rejoin? And I was looking back at like, when did they leave? And it was like two months ago. And
So that felt good that like sometimes people leave for whatever reason and then they realize the grass wasn’t greener on the other side or the reasons that they left. Actually, we did solve a problem for them. So I think in the big picture, when I think about attrition in general, I think that it’s mostly… either the at the end of the day like if you’re doing a good job providing good care and living up to what you’ve said in terms of your availability and access and all the the the things that you’ve kind of stated these are the important mission
and values and the way that we practice the reason that people usually leave is financial they either their job changes their health insurance gets better or gets worse or costs them more. And they don’t necessarily see or experience the value of what it is like to go back to a fee for service practice because they don’t remember or haven’t experienced the way it works in a fee for service practice. And they’re like, well, We have better insurance now or our insurance premiums went up so much. We just have to make this switch.
So usually I can’t think of anybody and I’m not trying to brag. I can’t think of anybody that’s left that was like, you guys did not live up to what you say, or you weren’t available enough or your boundaries suck or things along those lines. There’s usually a legitimate reason from the financials reason that, that they’re deciding to leave.
Yeah, absolutely. I would echo that. In my experience, the people who have left, by and large, it has been because of the financial piece. And it’s not always that they can’t afford it. It is often as well that they can’t afford it. So sometimes families are experiencing more financial hardship or a parent lost a job or especially one family recently died.
They had their second child and mom decided what, like trying to take care of two children and breastfeeding and doing all the things that work is just too much. So I’m going to take a break from working. I’m going to stay home for a while.
And so all of a sudden their family income saw a big drop. Right. And they had to make some hard choices about, okay, this is how much we have in the pot of money each month. Where are we going to allocate that? Right. And everybody has to make those hard decisions for themselves.
Every household has to ask those questions. And so when it comes to, okay, paying 200 a month for the two kids or whatever, often we are on the chopping block when those hard decisions have to be made. Right. Because it’s not a, necessity necessarily. It’s a luxury for many families.
And we have to understand that as DPC doctors, right? Like if the family has insurance or has another way of getting medical care, even if it’s not nearly as great as what we offer, Sometimes families are going to make that decision to go back to what is at least something,
even if it’s not as good as they wanted. Right. So that family left, of course, because of financial reasons. But I’ve also had an experience similar to what you just said of a family leaving and then wanting to come back because they went and they were reminded of the realities of the medical world, the insurance based medical world. and said, oh, okay, maybe actually it is worth that extra financial stretch to do that.
We ask like okay of course we can transfer your records can you give us a little bit more information on what’s going on or what’s changed just so we can get a flavor for why are they leaving are they not using it are my jokes not funny enough
uh are is our hours not what they’re looking for and it typically just comes down to finances which i completely understand like Most people have a budget. Most people have to make these choices. And as we’ve discussed on previous episodes, it’s not simply their finances that drives people to DPC because we have a lot of
people in our community that are quite well off that have no interest in DPC and would never even consider it. And on the flip side, we have a lot that are really scraping to get by, but see the value of it. And so I think most of it comes down to outside of just regular old,
like we have to trim things from the budget. It’s often a value perception. Is this worth it? And if I haven’t had to show my insurance card or get bills from my kid’s pediatrician three months later for a stuffy nose that turned into an ear infection that had to have an ear infection recheck,
And that was three co-pays and then three co-insurances. And you’re telling me I’m out $900 now or I owe $900 for those sick visits that went to my deductible. That calculus can change back once they realize, oh yeah, this is how fee-for-service healthcare actually works.
What do you think in terms of things, Marina, that help to reduce attrition? If we’re talking about attrition being a standard part of business, what are the strategies that you found or that you implement to try and reduce attrition?
Yeah, I think that touch points along the way, especially for those families who don’t need you very often are important. Recently, we had an episode on newsletters. then that was one of the goals behind my newsletter is to really, okay, some of the families,
like they pay my membership fee and they only reach out to me like once or twice a year. So it’s almost this guilt that I feel charging them when I’m charging them for that like single visit per year. And so I thought, well, a newsletter is really easy to do once it’s kind of,
once we have that system in place and it acts as a touch point so that the family is getting something, quote unquote, even when they’re not seeing me in person. Right. And it’s also a reminder to them that, hey, I’m here for you if you need anything. Right. Sometimes families just have it on auto charge.
I know I have things on my credit card auto pay that I forget I have because I signed up a long time ago. I was like, oh, I forgot I signed up for that thing. Right. So the newsletter acts as that kind of reminder of like, OK, Dr.
Cabello is here if I ever need anything or here’s some free information or here’s something about a local event going on that I can take my kids to and things like that. So I think that acts as a nice little reminder first that I’m here, but also as offering a little bit of something to them,
even when they’re not needing to see me in the office very often.
Yeah. I think in the family practice realm, it’s very different because the costs are much lower and people don’t want to need their doctor and we want regular touch points and all those sorts of things. So it presents us with the challenge of like getting in front of our patients,
especially those that have school aged kids who are not going to see on a regular basis. They’re not texting with the stuffy noses and the rashes and the poop pictures and all those sorts of things yeah we’re just seeing them on a less
regular basis so we want to proactively remind them hey we’re here for you and we can help and here’s the things that we offer whereas i think some if the fees were less you might just try and stay under the radar so that they forget that you’re
paying them on a regular basis um in in pediatrics and especially at the the higher price for for direct pediatric care i think it’s worthwhile to proactively show hey we see you you’re here we’re standing by and ready to help you when you need it and i think newsletters are a
great way to do that i had um a birthday recently and i actually absolutely hate getting the automated birthday reminder like emails from like i i got one from my my primary care doctor from like 12 years ago when i lived in a different city it was like happy birthday i’m like
Yeah. When it’s an automated text or an automated email, it feels so depersonalized that it doesn’t really matter. I actually pay my virtual assistant to send handwritten cards. I used to do it myself for the first couple of years. when I had a smaller panel and then things just got busier.
So I offloaded it and it has this little like wax seal stamp with the bunny on it. And it’s just, it’s handwritten. So it’s a little bit of a personalized touch for my members. So little things like that you can do.
that is such a different experience than just like the auto-generated like misspelled name happy birthday philip sort of emails that you get and you’re like dude that just wasted that tiny amount of electricity and now i have to waste my time grumbling as i clean out my inbox and those sorts of things. But I love that idea.
And I think the in-between of those could be something like you take a picture that’s in like a birthday hat or something like that. And I mean, you don’t have to do it for every kid if you don’t want to. You could do this every year and just update it to make sure that you don’t send
the same picture to the same kid twice.
Yeah.
Or just have like a happy birthday and then happy birthday, Leo, somebody in your staff sends those out or schedule. I mean, you could schedule that in an afternoon. You could just schedule that out for the whole year for the majority of the kids in the practice to just have an automated text message go out that says,
hey, happy birthday. And that’s so personalized and so different because they see you and they see your face and they get to show their kid like, oh, look, Dr. B sent you a happy birthday message. Yeah. That actually sparks at me that that is something that would be good to do.
One way that we found for our older kids, because attrition for one year olds, two year olds is quite low compared to the 14 year olds that really we see for their checkup, we see for their sore throat, maybe a mental health visit here or there. One thing that we do to try and say, OK,
like we’re still relevant and we want to make sure that we’re there for you. is we do a quarterly PHQ-9 and GAD-7 mental health screening. So people are used to, especially if they’re kids, if they were at a fee-for-service practice, the annual checkup in the summer where they do the mental health screening,
and then we don’t hear from you for a whole year. And a lot of things can happen mental health wise, obviously, during all that span. So what we say is like, we want to keep closer tabs. If there’s nothing going on, great. But it’s hard for parents to know often.
And I can’t, I mean, I’m sure you had this experience many a time. You go in for the quick summer checkup and they’re scoring super high on their GAD 7 or their PHQ 9 and like the whole… conversation shifts what instead we do is we just send that out and it’s automated
super easy if they flag high then we’ll reach out to them otherwise we just say like if you don’t hear from us keep going and we’ll send you another one in another quarter not everybody does it but everybody knows that like that’s something that
we’re keeping a close eye on and it takes almost no work on us but it shows our value and that we care
Yeah, that’s nice. I mean, you do have to have some sort of automation tool in order to do that. How do you do that? Is it through your EMR?
Um, so actually we just use Spruce and we have a standard like form link and we just schedule the text message that says, Hey, it’s time for your kids’ quarterly mental health screening, hand the phone to them. They’ll click this link. They put their name in, they fill out the GAD-7 and the PHQ-9.
It pops back to us in their chart and then we can look at those from there. So it’s pretty simple and easy to manage with about any EMR or something along those lines.
Gotcha. Yeah. Interesting. Yeah. I think that’s a great idea, especially since those teens, it’s often a hard sell. DPC is a hard sell for the parents of teenagers who really, at least per the parents, they say, oh, they just need their once a year physical. Most of the time when they actually join,
they need more than that because those teenage years can be tumultuous. And that’s when anxiety and depression start to arise. And that’s when just other issues can pop up sports injuries, concussions, all sorts of stuff. And so they do often utilize more than they think they will. Right.
Yeah.
Another thing is I have families sometimes who really can afford what I offer, but it’s, we talked about how their families who are kind of living paycheck to paycheck, but they really see the value. And then on the other end of the spectrum, there are families who really do have plenty of money to pay, but it’s,
that psychological understanding of the value, right? I recently had a mom reach out wanting to join. I know this family has plenty of money. They have multiple homes. They have multiple businesses. They own a ton of real estate. They’re doing just fine.
But it took a lot of messaging back and forth for her to finally decide after a few weeks of messaging back and forth, And ultimately, I just had to say, look, you’re paying for my accessibility, right? It’s like when you give a lawyer a retainer, right? You’re paying for that.
accessibility to them and that work going forward because you never know exactly what’s going to happen. And also just my time. Another doctor is not going to answer you at 8 p.m. for something urgent. I do that.
And in order to be able to do that, I have to limit my panel and I have to charge what I charge. Right. And so but even then, there will be families that just they feel like they haven’t used it in a while. They feel like they don’t need it.
Another reason for attrition we should mention is families just moving away. I have had many families. I would say the majority of my attrition that I’ve had is related to families moving away. They’re moving to a different state, some of them moving international, some of them just moving maybe an hour away,
but it’s too far of a drive for them to think that it’s worth it. How about you? Do you have much movement in your practice due to people just moving?
Yeah, we do. I mean, those are the ones that usually they like are really sad to break up because then they’re like moving away and have to find another doctor. And we always just try and like proactively help them. Like, what’s your new zip code? Okay,
let me plug it into the mapper and see who’s nearby and get you set up with a new practice. Because once people are used to DPC, they really don’t want to go back to fee-for-service. And so we just try and plug them in there. But I think that’s a major reason for attrition too.
If you’re taking good care of people, if you’re holding up to your promises in terms of access and availability and those sorts of things, then the financial and the moving are going to be the vast majority of why people are leaving your practice.
and i think that it is always surprising to me how people value that but i in terms of the value perception because we’ve had families that are on medicaid that are living paycheck to paycheck and i go through the meet and greet with them and i’m like As a reminder, we don’t take insurance.
And then they’ll be like, that’s all that it costs. Because they can do the math on missing a day of work versus being able to text and say, hey, does this need to come in? Or what’s the deal with this rash?
Do I have to take off half a day of work to have you look at my child’s eczema? Or can you do it over text message? They can do the math and realize that there’s the value there. So I’ve given up on trying to guess who’s going to want to join or who’s going to
think it’s worth their money. And instead just focus on trying to take care of the people that are in the practice and not let it bother me when people don’t join or that decide that it’s not for them.
Which brings us to another point is another big thing around attrition is how do we deal with it emotionally, psychologically, because it can feel like a rejection. It can feel like a breakup in a way, right? Especially when you’re early and you only have maybe a dozen families and one of them decides to leave.
It’s like, oh, I stabbed to the heart. Wait, what did I do wrong? Is there something that I failed to do? And we can get in our heads about it, right? We can They start to blame ourselves and think through everything we’ve ever done and think like, oh, no, like, was I not good enough?
Did I miss something in their communication? Did I this, that or the other? Right. And I would say if you find yourself doing that, just take a breath, pause and say most of the time what people do is 100 percent about them and not
about you.
Right. And just like just. Taking a deep breath and saying it’s OK, they’re making their choice and it probably has very little to do with me and what I did in this relationship. Right. It’s probably something to do with money, with making hard choices about finances,
with just maybe not seeing the value because they’re in a mindset or they’re in a headspace where they just can’t see the value. Whereas you can’t, right? And other families can. So as long as that’s not happening, as long as you’re suddenly not losing 90% of your families for some reason, please don’t blame yourself, right?
When families occasionally choose to leave. You can also use it as an opportunity to ask for feedback. If someone is leaving, find a professional way to say, Thanks for letting me know. I’ve really enjoyed taking care of your family, if that’s the case. And I would love your feedback.
Is there something that I could have done better in order to keep you enrolled? Right. And it’s just if you frame it as I’m just trying to learn for the future, most people will be willing to be honest.
Yeah, I think that it’s a little bit tricky over text message sometimes to get that across if it’s coming from the doctor, because you’ve had this ongoing text stream of the things when they’ve been sick and then to be like, yeah, we just don’t need you anymore, that sort of thing.
So what we’ll often do is say, hey, this is Kelsey, like our office administrator or something. reaching out just wanted to check in which just kind of sets the tone that like this isn’t actually like your doctor that’s checking yeah i think sometimes people more feel more comfortable just kind of like talking to the assistant or something
like that rather than having to be confrontational perhaps that that can be just kind of a helpful strategy for for making sure that you don’t make them feel put on
the spot per se if if you’re worried about that yeah so since you do that phil Have you had any surprising things come up from having your office manager ask parents those questions?
Not really. I mean, it’s usually they explain it when they leave. So I haven’t had anyone that really like stood out that like, we really didn’t like this. We didn’t like this about your practice in DPC. One time during COVID, this was when I was in fee for service.
People were not happy that I was talking about COVID and those sorts of things. So they left then because they didn’t think COVID was real. I mean, this was very early in the pandemic. Sure. And so there were things like that, but none since I’ve been in DPC that I’m like, oh, well,
we should adjust our approach or policies or anything like that, because most people say, hey, unfortunately, our finances just aren’t working out right. Or we had this big health issue and we need to scale back. And that brings up one more thing, too, that I think about. We’ve had several families over the years.
that one of the parents has had a serious health issue, cancer, those sorts of things. And they say, we just really can’t afford it right now to keep going with the membership because of all those other things. And the vast majority of the time, what we’ll do is we’ll just say, we don’t want to lose you.
We know that this is really stressful. Let’s just pause membership for six months, keep seeing us gratis, and then we’ll resume it in six months or we’ll check in and see where we’re at in six months or something along those lines. At the end of the day,
none of them are such high utilizers that like we’re losing a bunch of money and caring for their one or two children over that period of time. But it certainly helps them in a difficult moment. And I think it just breeds good trust and focus on the relationship.
And it’s come up just a handful of times over four years. And I think it has been really meaningful for those families to not lose that in a very difficult moment.
Yeah, absolutely. Yeah. I’m trying to think of if there have been other reasons. Oh, one other thing I can think of for some attrition is that I’m a pushover and I… Well, not necessarily that I’m a pushover, but that families will sometimes… utilize me just for the period of time that they needed me.
And before I established a minimum duration for my contract, this was happening not frequently on an absolute scale, but relatively more frequently that families would come with their newborn and then pay for just a couple months of care when they really, really needed that early newborn care and the high touch newborn care with all the questions.
And then they would leave. I didn’t That left me with an icky feeling because I could kind of tell that there were some families, not a lot, but some who would kind of just say, oh, I was only charging one twenty five a month for newborns at the time.
And so, oh, yeah, I can get like three visits a month for one twenty five. Like they were doing that calculation in their head. And I should have known better. And it took me some learning to realize, oh, there are some families that will treat you that way.
Right.
And so I think some attrition was that they never intended to stay. They used you for what they needed and then they left. Right. And I think that’s where meet and greets and things like that come in handy, because if you want to filter those sorts of families,
you can get a sense from something like a meet and greet if you’re afraid of that happening too much.
Well, I also think that that speaks to charging an appropriate amount. Like in family practice or in adult medicine, oftentimes they’ll charge less knowing that these patients aren’t really gonna go anywhere else. They’re gonna stick around. And so it’s gonna even out over time. Whereas in pediatrics, especially if it’s something like that,
like charging the appropriate fee that if they see you for three months and then cancel, that you’re not like behind because of that. You have charged an appropriate enough fee that, okay, It would have been nice if they had stayed for two years because the relationship and the revenue and all the different things that are,
that are generated through that. But they stayed for three months. I got paid. They got what they needed. Maybe they’ll send a friend my way, but there’s no love lost between us. Whereas if you’re putting in a ton of work and especially in adult patients where
they’re a lot more complex and it takes a lot of time to get to know them and all the different things and get all their med straight and whatnot. that it can be a little bit of a different calculus. But I think that if we price ourselves appropriately,
then it will reduce the resentment if they do stay for a short period of time and then move on. But I think that giving an annual discount is a great way to kind of be like, hey, it’s this much per month. But if you want a discount,
maybe do an annual membership and then that also will reduce attrition certainly.
Absolutely. all right so lastly before we finish this conversation what about numbers some of you might be wondering okay what’s the percent of attrition that i can expect i mean is there a magic number no but i would say in my experience somewhere between
five or ten percent attrition per year is what i’ve experienced what about you phil
I think that’s a really fair number. I know that like in adult DPC that they often talk about like 15 to 20%. I think it’s less in pediatrics in general. So I would say five to 10% makes sense of attrition per year where people are cycling and cycling out.
And I think that is where I would land too.
Yeah. And I would imagine part of that is part of why we are lower than maybe family medicine is because our prices are higher. So that entry point is higher. That alone is filtering people who truly value what we offer and are willing to pay that higher price for it.
Right. People aren’t accidentally signing up. Like they’re doing the math and being like, okay, I can afford this for right now.
Exactly. Yeah. All right. Well, that’s what we have to say about attrition. Lots of different reasons, mostly financial. It’s not about you. It’s probably about them and about five to 10% per year. We hope you found this helpful and until next time.
