A pediatrician recently posted in the Pediatricians Who Do DPC Facebook group describing a familiar kind of exhaustion. She’s charging $100 to $150 a month, families have come to expect unlimited access, and a subset of her patients are now showing up one or two times a month. Do the math and she’s earning $50 to $75 an hour before overhead — less than many hourly employees, and a fraction of what her training and liability are worth. The replies were sympathetic, but they also revealed how common this trap is, and how many of us have fallen into it more than once.
I have. When I opened my practice, I charged $75 a month for older children and made unlimited visits part of the promise, the same way most DPC pediatricians do. It felt generous and aligned with the DPC ethos of removing barriers to care. Then I started seeing the kids who most needed what I offered: complex, integrative cases requiring therapy, hypnosis, or bodywork every week or two. Those are exactly the families who most value a flat-fee model, because their utilization under fee-for-service would be catastrophic. But that same intensity of need, unpriced, becomes catastrophic for the physician instead. My schedule filled with families whose care I loved providing and whose economics I could not sustain. Something had to change.
Why unlimited visits are especially risky for integrative and functional practices
The flat monthly fee was designed around the actuarial logic of primary care: most healthy kids need only a handful of visits a year, so the physician can average across a panel and come out ahead. That logic holds reasonably well for well-child checks, sick visits, and routine anticipatory guidance. It breaks down fast for anyone offering integrative, functional, or lifestyle medicine, because our visits are longer, our follow-up cadence is tighter, and our patient population self-selects for complexity. Families come to us precisely because they need more than a fifteen-minute conventional visit can offer. An unlimited-visit promise, in that context, isn’t a generous add-on to the membership — it’s an unpriced service line that can quietly consume the entire practice.
I’d also gently note what that Facebook thread implied without quite saying it outright: this pattern seems to hit women and integrative-minded physicians disproportionately hard. We tend to build models around access and relationship rather than around protecting our own time, and families — reasonably, given what we’ve offered them — take us up on it. That isn’t a character flaw to fix by working harder. It’s a pricing structure that needs to reflect the actual time being delivered.
What I changed
I raised my membership prices to a level that reflects sustainable value, and I built a visit limit into the standard membership so that “unlimited” no longer means “unbounded.” That alone fixed the baseline problem for most families, who genuinely do only need a handful of visits a year.
But raising the floor didn’t solve the question of what to do with the families who need genuinely intensive, ongoing therapeutic work — the ones who were the whole reason I built an integrative practice in the first place. For them, I created a different on-ramp: an integrative consult package, prepaid, that includes up to five hours of visit time to be used within three months. It lets us do real diagnostic and therapeutic work up front without me guessing at how many visits a case will need or discounting my time to make an open-ended promise. If, after that package, a family needs ongoing care, we transition to a custom membership priced around the actual number of hours I expect to spend with that child each month — not the standard age-based rate.
This past summer that model was tested by one of the more difficult cases of my career: an 8-year-old girl with Level 1 autism, significant anxiety and depression, and two prior suicide attempts by jumping from a moving car. Her mother, herself a therapist, had run out of options. We started with the integrative consult package, at $1,500, and used techniques drawn from hypnosis and CBT, delivered through drawing therapy that met the child where she was developmentally and emotionally. She built real tools for managing her internal experience, and her symptoms improved meaningfully. When the package ended, we transitioned to a custom membership at $300 a month, structured around two 30-minute therapy visits monthly. Her mother told me she was relieved simply to have a stable, known container for ongoing care — no more guessing what the next crisis would cost, or whether help would still be available when it was needed.
The general tradeoffs worth naming
Unlimited visits under a flat fee has real upside. It removes the friction and anxiety of a fee-for-service ticking clock, which matters enormously for anxious families and for the kind of exploratory, iterative work that functional and behavioral care often requires. It’s simple to explain and sell, and it signals trust: I’m not going to nickel-and-dime you for calling me back. For low-utilization, standard pediatric panels, it can work exactly as intended, letting the physician average across the panel the way the model assumes. It’s also, frankly, an easy pitch during a sales call — “unlimited” is a word families understand instantly, and it can shorten the path from prospective member to signed contract.
The downside is that “unlimited” externalizes the risk of high utilization entirely onto the physician, with no mechanism to reprice as a patient’s needs change. It rewards, structurally, the sickest and most time-intensive patients finding you — which is wonderful for your sense of purpose and terrible for your hourly rate, unless the fee was set with that reality in mind from day one. It also makes it very hard to say no later, since families who signed up under an unlimited promise reasonably feel entitled to it, which is exactly the bind our Facebook colleague described. And there’s a slower, quieter cost too: physicians who feel taken advantage of, even by families who are simply using what they were sold, tend to start resenting the very patients they built their practice to serve. That resentment shows up in burnout, in shorter visits, in a subtle withdrawal of the warmth that made the relationship-based model worth choosing in the first place. Nobody signs up for DPC to end up quietly dreading their schedule.
My recommendation: put a visit limit in writing, then be as generous as you want
If you take one thing from this article, let it be this: build a defined visit limit into your standard membership contract, even if you never plan to enforce it strictly. This is not about becoming stingy or abandoning the spirit of DPC. It’s about the difference between generosity you choose and generosity you’re contractually obligated to provide indefinitely, whether or not it still makes sense for your practice.
Those are not the same thing, and the difference matters enormously in practice. A written visit limit costs you nothing when a family’s needs are ordinary, because you’ll rarely if ever come close to it. But it gives you something you cannot get any other way: the standing to extend grace on your own terms, case by case, without ever having to claw back a promise. I did exactly this recently for a newborn who was hospitalized twice in the first month of life, once for jaundice and once for RSV and COVID, and who needed roughly eight visits in a single month. I didn’t hesitate to go well beyond any cap I might have set, because that family needed me and because I was the one deciding to give that time, not fulfilling a contractual minimum I’d locked myself into at signup. That’s the version of generosity that feels good to give. Generosity you can’t legally or practically retract, once a handful of families start relying on it every month, starts to feel like something else entirely.
This is the part that’s easy to underestimate before you’ve lived it: you can always loosen a limit for a specific family in a specific circumstance. You cannot easily tighten one after the fact. Renegotiating a membership contract with a family who has spent a year assuming unlimited visits are theirs is one of the more painful conversations in independent practice — it reads to them as a broken promise, even when it’s really a physician correcting an unsustainable structure. A visit limit set at the outset, with the explicit understanding that you may exceed it when a family truly needs it, avoids that conversation entirely. You keep full discretion. You just stop handing away unlimited discretion to the other side of the contract.
Conclusion
The Facebook post that prompted this article, and my own early years in practice, point to the same underlying lesson: flat-fee DPC only stays sustainable when the physician retains control over how much time any single membership actually buys. Unlimited visits sound generous, and in the moment of signing a new family, they are. But a promise with no ceiling isn’t really a pricing decision at all — it’s an open-ended bet on how healthy your panel turns out to be, placed with your own hourly rate as the stake. Integrative, functional, and lifestyle-medicine practices lose that bet more often than conventional panels do, because the families most drawn to what we offer are, by definition, the ones who need more of our time.
The structure that has worked for me — a capped standard membership, an integrative consult package for focused, time-limited work, and a custom membership priced to the hours a complex patient actually needs — isn’t the only way to solve this, and your numbers and specialty will shape your own version of it. But the underlying principle should be non-negotiable: write a visit limit into every membership you offer, price your standard fee as if that limit will sometimes be used, and then decide, family by family, visit by visit, when you want to be more generous than the contract requires. Keep that generosity as a gift you give on purpose, not an obligation you signed away before you understood its cost. Your patients will still get a physician who shows up for them in a crisis. You’ll just also still be practicing, sustainably, five years from now — which is the only way you can keep showing up for anyone at all.
If you’d like more guidance launching or growing your own direct care practice, DPC Pediatrician offers a startup guide, coaching programs, on-demand courses, and even one-on-one consulting.
