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Primary care is the bedrock of reform of the US health system. New payment and care delivery models emphasize the importance of primary care medical homes with reimbursement prioritizing value over volume. It remains unclear how best to restructure US health care spending to attain the Triple Aim (ie, improving the experience of care, improving the health of populations, and reducing per capita costs of health care) as well as the 4 C's of primary care (contact, continuity, comprehensiveness, and coordination). Of the myriad models emerging over the last decade, direct primary care (DPC) is unique in its renunciation of insurance companies and other third-party payers. Instead, patients contract directly with a primary care physician to pay a recurring out-of-pocket fee in exchange for a defined set of primary care benefits. 1 DPC models vary in their structure, yet they generally provide coverage for acute care and long-term care, basic disease treatment, discounted prescriptions, vaccinations, screening tests, and basic care coordination. Physicians can choose to include services that might not traditionally be reimbursed in fee-for-service models, including electronic correspondence with

To the Editor The Viewpoint by Dr Adashi and colleagues 1 raised several criticisms of direct primary care (DPC) that ignored the context in which DPC has emerged. Direct primary care has evolved in affirmation of the primacy of the patient-physician therapeutic relationship and rejection of bureaucratic and economic burdens on clinicians.The authors' suggestion that DPC practices promote adverse selection biases favoring wealthy, healthy, and nonminority patients relies on a false conflation of DPC and concierge practices. Unlike the dominant third party-based model or concierge practices that bill insurance, DPC practices relying on a flat monthly fee are not financially motivated to select patients based on health or socioeconomic status. In fact, DPC practices aim to provide as broad a scope of care as possible on the premise that individuals have the capacity to vote with their feet.The authors suggested that DPC would exacerbate gaps in the cost of care. However, out-of-pocket costs for mandated insurance products have ballooned for US households. 2 For many uninsured and underinsured persons, DPC practices are an economically feasible option that provides access to longitudinal primary care.The claim that DPC "lacks the necessary oversight needed to hold physicians accountable for data reporting as well as individual and population health outcomes" 1 is at odds with the central tenet of the clinician's fiduciary responsibility 3 -to place the patient's interests above others, including data reporting and population health outcomes.