Six DPC Platforms, Four Different Billing Units: The Question That Decides Your Bill in Year Two
Across two weeks in September we hosted six Direct Care platform vendors for live demos: SigmaMD, Elation Health, Akute Health, Cerbo, HealthBook+ and Hint Clinical. Same format every time. The vendor drove a working product for thirty minutes, then I asked the same four questions as the accountant in the room rather than the buyer.
If you missed them you can watch them here: Goodmancpa.com/webinars
One of those four separated the six more sharply than anything else on the calls.
Where does the price step up?
Six vendors, and four different billing units came back. Not four different prices. Four different answers to the question of what you are actually being charged for.
What the billing unit decides
Practice owners compare monthly rates because that is the number on the slide. A rate tells you what the platform costs this month. The billing unit tells you what it costs over the next five years, because it governs whether the software line on your profit and loss moves when the practice grows.
Here is what came back across the five systems of record.
Per provider. Billed on whoever signs notes or prescribes, with every other staff account complimentary and uncapped. Your bill moves when you hire a second clinician. It does not move when your panel doubles.
Per user, by role and by full-time or part-time status. Every seat is billed, and the rate depends on what that person does and how many hours they work. Your front desk hire shows up on the invoice. So does converting someone from part-time to full.
Per member. A small fee for each patient on the panel, designed so the bill starts low and rises with revenue. Every signup form your front desk processes adds to it.
Base subscription plus per-seat fees. A base covering at least one clinician, a fee for each additional clinician, and a smaller fee for each admin seat.
A sixth shape showed up from the platform that is not an EHR: per member per month, charged on top of whatever system of record you already pay for.
Price it at the panel you expect in eighteen months
This is where the unit stops being trivia.
Take a practice at 300 members with one clinician, growing to 600 over the next eighteen months. On a per-provider platform that practice pays the same rate the whole way. On a per-member platform the software line doubles, for the same clinician doing the same work in the same building.
Now flip it. A practice that stays at 300 members and adds a second provider and a part-time medical assistant sees the opposite: the per-member bill barely moves, and the per-provider and per-seat bills both step up.
Neither model is wrong, and neither vendor is hiding anything. They are priced for different practices. The mistake is comparing two of them on this month's number and discovering the divergence in year two, when switching has become expensive.
So price every platform three times on one page: your panel today, your panel at 500 members, and your panel with two providers. Ask the vendor to produce that table in an email.
Three more questions worth asking in those words
What is genuinely included, and what is a separate line? Three of the five systems of record meter the AI scribe, the patient portal or the fax page count away from the base subscription. One prices the patient portal by active patient count. A base rate tells you very little until you know which switches a practice your size turns on in month one.
Which of my current tools does this replace? Pull the general ledger and list every software charge on it before the demo. Owners find a form builder, an e-signature tool, a scribe, a survey product and a video platform sitting in that list. Several of these platforms absorb three or four of them, and two expect you to keep paying a third party for membership billing or messaging. The new subscription minus what you cancel is the only number that belongs in your budget.
What does the switch cost in weeks, not dollars? Three of the six said migration carries no fee at all, two of them emphatically. The cost is the weeks your team runs two systems, cleans an export and rebuilds workflows. Timelines on these calls ranged from ten business days to a requested thirty-day window, each one conditioned on how many patients sit in the old system, and one vendor said plainly that the workflow migration lands on the practice.
The fifth question, which never came up in six sessions
Four questions went into every demo. A fifth one belongs there, and across roughly four and a half hours of recorded vendor answers it did not surface once.
Not one vendor stated who owns the patient data, how a full chart set comes out, in what format, or what happens to your records after you cancel. Not one named a single data type that fails to migrate. The closest anyone came was a founder saying he did not want to make it sound like a perfect process, and then naming nothing.
That is not evasion. It is a question that is absent from the standard demo agenda, so it does not get answered, so it stays absent. Ask it at the demo, where the answer costs you nothing.
It lands harder in Direct Care than anywhere else. The panel is the business, the chart is the record of the relationship behind it, and you are choosing the company that will hold that asset. If you ever sell, take on a partner or merge into a group, somebody performs diligence on those records, and a CSV of billing reports is a very different answer from a structured export of the full chart set.
Put these five in an email before the second call:
- Who owns the patient data, in the words of the contract?
- On the day I give notice, what do I receive: full charts, documents, notes, labs, the payment file, the membership roster?
- In what format, and is it a structured export or a pile of PDFs?
- How long after cancellation can I pull it, and what does it cost?
- Name the data types that do not come across in a migration.
Ask for the replies in the same email as the quote, and keep them with the contract.
What each of the six actually said
We put the six sessions into two documents.
The DPC Tech Stack Comparison Guide runs one page per platform with identical headings so the pages read side by side: pricing model, included versus add-on, migration, data ownership, payments, integrations, reporting, patient-facing, AI, and a panel on each page listing what that vendor did not disclose. HealthBook+ sits on its own page rather than in the comparison tables, because it runs alongside an EHR rather than replacing one.
The one-page demo companion is the version you take into the call: the four questions in the words to use, what the six publish on their own pricing pages, and the arithmetic for your true stack cost per member per month.
Neither document ranks the six or names a winner. Which platform fits depends on your panel size, your staffing and your service lines, and you are the only person holding all three numbers.
Nate Goodman, CPA is the founder of Goodman CPA, which works exclusively with Direct Care practices — Direct Primary Care, functional medicine and integrative medicine — nationwide. The firm has identified $3.16M in tax savings across 70 tax plans for practice owners who left the insurance model behind. Karen Saylor's practice, Coastal Maine Direct Care, saved $27,436 in 2025.