What does concierge or direct primary care do for you? It gives you outstanding care at a reasonable cost. Your doctor cares for only about 500–800 patients instead of the typical 2500–3000 individuals. Instead of seeing 24+ patients per day for an average of 10–12 minutes of “face time,” you get same-day or next-day appointments for as long as necessary. You get intensive wellness advice through preventive medicine direction, immediate care of those episodic problems that arise every so often, and complete attention to complex chronic diseases (heart failure, diabetes with complications, etc.) with much less need to refer to specialists.

But when it is necessary for specialists to participate, the PCP plans and coordinates the care process. And most important, the PCP gets to know you as a person, part of a family and a community, developing a caring and trusting relationship. You will have fewer tests, X-rays, and specialist visits, fewer ER visits, and fewer hospitalizations. Some practices offer generic medications at cost and deeply discounted prices through arrangements for imaging and lab tests.

Here are four direct primary care practices to illustrate typical fees. For example, AtlasMD’s (Kansas City, MO) annual fee is $600 for a young adult and about $1200 for someone over age 65; Dr. Neuhofel’s (Lawrence, Kansas) is $708 (adult under age 70) to $948 (70 and older) annually for an individual and $1668 for a family of four.

Drs. Izbicki (Erie, PA) charge $1380 per year per individual 30 and above and $2340 for a family with any number of children under age 19. In Columbia, Maryland, Dr. Sarah Zahaar recently left a Johns Hopkins group practice and began a DPC practice called Oak Tree Primary Care. She charges $99 per month with a 15% discount for those who pay annually, just over $1000 per year. In addition, she has discounts for families and children. From her website, here is a link to a short video on DPC.

As Jon Izbicki told me, “Our monthly fee is less than what it costs to rent a parking space downtown for the month.” Even the more expensive retainer or concierge practices are still within reason for many. $2000 is about $5.50 per day. How many people spend that much per day at Starbucks? Or, consider the monthly/annual cost of internet, mobile phone, cable TV, and streaming.

As of 2021, the average expenditure per month (different organizations reach somewhat different conclusions, but the following is a good average) for internet, cable, and streaming services is $156 per month or $1768 per year. Add to that mobile phone service, and the total is well above $200 per month or $2400 per year. So, perhaps $1500 or $2000 — undoubtedly real money — is not such an onerous expense for comprehensive primary care when prioritizing healthcare expenses relative to other expenses.

Suppose you have a high deductible health insurance plan from your employer or from the exchanges with a health savings account (HSA). In that case, you can pay for the membership/retainer with tax-advantaged dollars and save considerably. And since the PCP will help you avoid digging into the deductible by preventing the need for expensive trips to the specialist, the emergency room, or the hospital, and for excessive laboratory or imaging tests, you will also save those dollars.

I predict that (absent a significant change in insurer behavior) direct primary care will likely be the future of primary care payment. It means that the patient will obtain genuine assistance to first prevent chronic illnesses from occurring; second, episodic care for those issues that pop up during the year; third, careful care of complex chronic diseases, and fourth, thorough coordination of the care of chronic illnesses, all at a reasonable cost which will be transparent.

Importantly, you have a PCP who has the time to listen — to listen deeply, resulting in a return to relationship medicine with mutual trust and respect.

Those who already have typically limited deductible insurance — commercial or Medicare — might argue that these various direct primary care models represent an added expense, not a savings. Yes and No. It is an added expense, but the potential savings can be substantial. For example, each of the three practices referred to above makes generic medications available at wholesale prices — considerable savings for many individuals.

Those with no insurance — for whatever reason — will find that they can obtain good quality primary care at a reasonable price from one of the direct pay or membership practices. It will cost much less than going to an urgent care center or an ER.

Perhaps Medicare and Medicaid will decide that it makes eminently good sense to pay the retainer for their enrollees and thus ensure their members get superior primary care at a reasonable cost. Meanwhile, save Medicare and Medicaid enormous total dollars. (In an earlier article, I reviewed what one company, AbsoluteCare, has done to reduce expenses while dramatically improving care for some of Medicaid’s most expensive patients.)

Some companies such as Erickson Senior Living that sponsor Medicare Part C (Medicare Advantage) plans have learned that by using DPC, although it costs more upfront for primary care, the total costs of care come way down, making the DPC investment a “no-brainer.” The image at the top suggests that older people can receive excellent care from a DPC/concierge physician resulting in better health and a longer life.

This concept could apply equally to commercial insurers, but they have largely avoided DPC, retainer, and concierge practices.

What about employers? The average cost per family, per the Kaiser Family Foundation, was about $22,463 in 2022, with the employee contributing $6106. Although KFF notes that the general annual deductible is $1763, many companies have very high deductibles, sometimes as high as $10,000 per family per year. For a family with members that have chronic illnesses, the costs of healthcare are thus substantial, indeed a level that makes one a medical pauper if you or a family member gets sick. In addition, employees will arguably feel their employer has walked away from them and saddled them with costs they cannot bear.

The company can partially offset the inherent anger this generates among its employees by paying the fee for direct primary care practice. It is especially valuable for individuals with multiple chronic illnesses since quality primary care can mean much better health, fewer tests, prescriptions, specialist referrals, and hospitalizations. In addition, since businesses are essentially self-insured using the “insurance company” as the administrator, their costs will decrease with this approach.

The bottom line, the company pays for the DPC doctor but reaps the benefit of lower total costs and a healthier employee who is more content and misses many fewer workdays due to sickness. More details are in my previous article, “Company paid concierge style primary care.”

Once companies recognize this advantage with its increased employee health yet reduced costs, employers will be the major reason for direct primary care membership/retainer-based practice growth in the coming years as they will essentially demand that level of service for their employees — and in so doing they will be reducing their company health care costs as a result of high-quality primary care.

The exact number of physicians in DPC practices is unclear, but an estimate by Concierge Medicine Today (CMT) in 2022 pegs the known number at about 10–25,000. CMT also notes that many combine insurance with membership fees, e.g., MDVIP; not exactly DPC anymore, but still an ability to limit the number of patients per doctor and give more attention to each.

More doctors will convert once the general population understands the advantages and begins to ask for them and demand them. There are many good reasons for an individual to connect with a direct primary care physician — better quality care, a return to relationship medicine, and often a significant cost saving despite the fee. Consider the copay and deductible savings if you spend less time in a specialist’s office and avoid visits to urgent care centers, the ER, and the hospital, including the copays for specialty testing, lab work, and imaging. Most importantly, you will have better health. That is priceless.

This is the 17th in a series on America’s dysfunctional healthcare delivery system. Here are links to the first and a recent article.

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Another variant, rather than establish their own primary care clinic, some companies have decided to purchase the retainer/membership for their employees in a direct primary care (DPC) practice. They choose one or more practices that offer the type of comprehensive primary care that has proven to be effective in both enhancing health and lowering total costs. Alternatively, they place a sum of money in the employee’s HSA or HRA which can be used pay the membership fee for the DPC physician of the employee’s choice.

Another example is a Catholic Health Initiatives (CHI) option for their employees. CHI’s Nebraska and southwest Iowa division with about 20,000 staff members established a DPC clinic and about 1100 employees opted for it in the first year, 2018. Total costs have and patient satisfaction improved.

Image from article explaining CHI program

Note, I use DPC here to refer to any of the variants of direct primary care, membership care or concierge care. In all cases, I refer to a physician who has a panel of about 400–800 patients rather than the usual 2500–3000, offers same or next day appointments for as long as necessary, responds to text and emails and makes their cell phone number available 24/7. They offer episodic care, full attention to complex chronic illnesses but when a specialist is needed, they coordinate the care and assist in making an expedited appointment. They are razor focused on wellness maintenance and disease prevention and may work with a health coach, nutritionist or others in a team manner. Some, but not all, offer reduced rates with local laboratories and radiology services and a few make available generic medications at cost. There is an annual or monthly fee for the physician’s services.

Image from Premier Health

Insurers have been slow to enter this field, preferring to let the employer purchase DPC rather than offering it as part of their policies. But it can work for the insurer. For example, the individual either directly or via the exchanges selects an insurer that partners with DPC physicians. Part of the payments to the insurer go to pay the DPC doctor, perhaps $100 -120 per month, and the remainder purchases a catastrophic policy with a reasonable but not excessively high deductible. To make the program even better, some insurers contract with a DPC group that also includes a health coach for each patient along with classes on health and wellness at no additional charge. The downside, of course, is the individual does not have full free choice of their preferred DPC physician.

A similar approach begins with a DPC physician group that offers self-insured employers a package of direct primary care along with insurance for specialty care and hospitalization. The employer pays the primary care physicians’ group which uses part of the premium to pay for the DPC physician care, including extensive preventive care and chronic disease management and, often, including common labs, radiology, generic meds, and vaccines. There are no co-pays nor deductibles. Specialty care and hospitalization is covered by the insurance component and may or may not include co-pays and deductibles as determined by the employer

Iora Health (a Boston-based company acquired a year ago by One Medical that in turn is being acquired by Amazon) also largely deals directly with employers or unions to purchase complete expanded primary care for their employees or members. An example is the Dartmouth clinic for its employees.

These are but a few of the new approaches being taken by employers and enterprising organizations to improve primary care and in the process improving the total health of company employees and their families. Do these represent the future? Only time will tell. But employers and insurers will recognize that high quality comprehensive primary care, although it costs more than typical primary care, will actually reduce their total costs while improving quality and satisfaction. Then I predict employers who appreciate the value of these arrangements will increasingly gravitate to DPC models.

Note: The companies listed are for illustrative purposes only; inclusion is not an endorsement. I have no financial arrangements with any of them.

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The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality, and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls by government and commercial insurers and regulations, also by insurers, that reduce the trust and core interactions between doctor and patient. The doctor, not by choice, is the insurer’s client. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an Op-Ed that paying the doctor directly is better for all concerned.

Some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves. They have essentially said, “I won’t take it any longer; this is not good for my patients or for me.” They have also said it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system — direct primary care — rather than wait for others to fix it for them.

The concept of direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care, and it always means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principal payment systems.

One is for the patient to pay the doctor directly for each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list — transparency. This is sometimes called direct pay or “pay at the door,” unlike how it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of care for the year paid by the month or annually. This basic model comes with many variations and may be called direct primary care (DPC), membership, retainer, or concierge. Despite the various names, they all have certain characteristics in common, but there are many variations in how the practice functions.

All of these models offer a reduced patient-to-doctor ratio; instead of the typical 2500–3000+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or a high of about 800 for a panel with mostly low-risk patients. Some accept insurance and also charge a lesser retainer; most just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to offering same or next-day appointments lasting as long as necessary, a comprehensive annual examination, email and text communications, and an invitation to contact the PCP on their personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER, and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing, imaging, and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the monthly/annual subscription cost of direct primary care.

Many PCPs in these models only work with specialists who are willing to discount their fees for those of their patients who pay cash, have high deductible plans, or have no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact, DPC/membership/retainer/concierge practices can be of a quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes — “blue collar” concierge medicine.

Fees range from about $500 to $2000 or more per person per year. [I will ignore those doctors who charge a very high fee for “exclusive” services.] By some degree of common usage, those on the lower price end often refer to their practices as direct primary care or membership, whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or number seen per day, the extent of the annual evaluation, and added values such as following one’s patients in the hospital and in the ER.

For those with high deductible insurance policies from work or the exchanges, connecting with a direct primary care physician can offer significant savings. The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction — a return to “relationship medicine.”

With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration, more satisfaction for doctors and patients alike, and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down, way down. A triple win.

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