Concierge docs: Oregon physicians switch to retainer payments amid primary care shortage

Editor’s note: This is the first of a three-part series on the increase of concierge or “direct care” practices, what's driving the trend and concerns over its implications for the larger health care system. Click here for the second and third installments.

When Baskin Clinic opened its doors in Portland in January 2005, it was one of the first concierge practices on the West Coast that didn’t take insurance but charged patients a flat fee.

It also marked a bold plunge for Dr. Lester Baskin. He gave up a reliable paycheck at Kaiser Permanente and used his own money to hire a medical assistant and rent a 1,000-square-foot office in northwest Portland.

They only had a few family friends as patients to start. Today, his practice is one of the largest of its type on the West Coast, with eight doctors, two offices and 2,000 patients. 

And it keeps growing. 

“Every couple of years we hire a new doctor,” Baskin said. 

Unlike traditional medical practices that primarily rely on insurance payments for revenue, concierge physicians charge patients a monthly fee or retainer. The practices promise longer appointments, extra services and personal access to the doctor.

As more physicians switch to this model, it’s triggered a national debate, with critics saying the trend leads to less access for some patients and harms underserved populations. But the nine concierge doctors interviewed by The Lund Report say that with the way the health care system is changing — with bigger patient loads, shorter appointment times and increased paperwork demands — they had no choice but to change their practice.  

“I was either going to do something different — or leave the practice of medicine altogether,” Baskin said. 

Numbers are growing

A number of terms are used to describe concierge care, such as direct primary care, subscription or retainer medicine. While some clinics take insurance, others do not. The Lund Report is using “concierge” as an umbrella term for all of these practices.

The Oregon Department of Consumer and Business Services only tracks the minority of these firms that, like Baskin’s, charge a fee and don’t take insurance. These practices are known as retainer or direct primary care. The state has certified more than 50 such practices — including eight new ones since January. 

Nationwide, estimates indicate there could be 15,000 or more concierge practices in the U.S. Industry analysts expect them to keep growing as much as 7% to 10% a year. 

In Oregon, most of them are located in urban areas along the Interstate 5 corridor. But there are also clinics in Astoria, Bend, Enterprise and Hood River.

Their growth coincides with primary care shortages in Oregon and the rest of the country that are hurting patient access and health outcomes. One survey found that patients around the country trying to get a family medicine appointment waited far longer in the Portland area than in other cities.

Critics say concierge practices exacerbate that shortage by siphoning off patients who can afford retainers, leaving fewer physicians to care for the rest. But physicians who’ve made the move say the increasingly demanding health system  — with new requirements to fill out electronic health records, an increasing number of billing hassles and coverage denials from insurers — is to blame, pushing burned-out physicians to retire early and deterring medical students from pursuing primary care. 

The Lund Report interviewed nine physicians who switched or are switching from a traditional to a concierge practice. Most offer reduced rates to some low-income patients, and several said they try to keep the monthly fee as low as possible to be affordable for a wider range of people.

But they acknowledge they’re largely serving patients who can afford their care. 

One of them switched to a concierge practice because insurance payments weren’t enough to keep the lights on. Eight others, including a physician who answered questions by email, opened a concierge practice because they no longer wanted to see so many patients each day. Insurance pays clinics per patient visit, not for the time a physician spends with a patient. That means the more patients a physician sees, the more money a clinic makes.

But shortening appointments can lower the quality of care, concierge doctors say. Not only that, it can turn the work day into a demoralizing grind. 

Exclusive first practice

The first concierge practice was founded in Seattle in 1996 by Dr. Howard Maron, former team doctor for the Seattle Supersonics. His clinic, MD2 or MD Squared, charged families thousands of dollars a year for white glove service, including home visits in the middle of the night. Today, it has clinics in 15 states and charges $24,000 for the first family member. 

Through a public relations company, MD2 physicians declined to answer questions or be interviewed by The Lund Report. Another large concierge company, MDVIP, also didn’t respond to a request for an interview. It has clinics in 44 states and charges Oregon patients nearly $2,200 a year.

That’s more than the average, according to a 2024 survey by the American Academy of Family Physicians. A poll of 177 physicians found they charged $20 to $49 for a month for children and $50 to $100 for adults excluding seniors. 

Practices usually charge more for the elderly and many offer a family rate, the survey found. 

Baskin modeled his practice after another trailblazing Seattle physician, Dr. Garrison Bliss. He opened a concierge practice a year after MD Squared but wanted to be affordable, charging patients $1,000 a year.

Bliss considers this model the only safe career path for physicians because it frees them of the bureaucracy and control leveraged by insurers. But he said it takes time to build the business.

Baskin relied on his initial patients to expand his practice, asking them for the contact information of anyone who might be interested in his practice.

“I probably made a thousand phone calls the first year,” Baskin said. 

Now patients hear about him through word of mouth, which is how most concierge practices expand, the physicians say.

State tracks only a portion

Concierge practices must comply with general regulations governing telemedicine, consumer protection, scope of practice and medical malpractice. But there’s not a lot of oversight beyond that.

Oregon only requires concierge practices that don’t take insurance, known as retainer medicine, to be certified by the state under a law passed in 2013. The practices must have agreements with their patients about what the flat fee covers and be transparent about not taking insurance on their websites and in their marketing materials.

Once a year, these practices must report to the Department of Consumer and Business Services to show their businesses are financially viable and ethical.

“They want to make sure that you're not cherry picking patients and excluding people or throwing people out,” said Dr. Rob Rosborough.

Roborough worked for a traditional practice in Silverton for 20 years before deciding he no longer wanted to see 25 patients a day.

“You never felt like you had enough time with them,” Rosborough said. They might come in for shoulder pain but what’s really going on is their mom died and you need to spend time with them.”

Appointments at his clinic, Township Health DPC, last at least 30 minutes and, like most concierge doctors, he gives patients his cell phone number and email in case they need to contact him after hours. 

Many concierge practices like his offer some services not usually performed in a primary care office, including full body dermatological checks and mental health counseling. As the longtime medical director of a drug and rehab center based in Salem, Rosborough offers drug counseling, too.

He also performs vasectomies for men and circumcisions for babies and has an in-house pharmacy that sells generic medications at prices just above wholesale. One of Rosborough’s patients, who takes three pills a day, would pay $90 a month in copays through his insurance. Instead, he buys them from Rosborough and pays $9 for a 100-day supply.

Rosborough has an agreement with Quest Diagnostics to save patients money on lab tests: They pay $3.10 for a blood count test, $3.84 for a metabolic panel and $5.62 to check lipids or cholesterol.

Kristen Beyer, one of Rosborough’s longtime patients, said she saves money using his image specialist. 

“I have not had an X-ray done at a hospital or an insurance facility in 10 years,” she said. “When my son broke his arm, I think it was $80 for the X-ray and to have the radiologist read it. My insurance would have been several hundred dollars.”

She cited her personal connection to Rosborough as one of the biggest advantages of seeing a retainer or direct care physician. Her husband, who owns a hardware store, and two sons also see Rosborough. They pay $215 a month, which includes $175 for two parents and an unlimited number of children. Their young son costs $40 a month.

“I love that I can message him and say, ‘I've been having this or I've been having that, and what do you think?’ And he'll give me an honest answer,” Beyer said.

Patients' retainers don't eliminate need for insurance

Beyer’s family has health insurance for services not covered by Rosborough, like hospital and specialist care. She’s also needed it for urgent care when he’s on vacation.

Rosborough recommends that all of his patients have insurance or a backup plan. But about 30% of them are not insured, he said.

Another concierge physician, Dr. Maureen Mays, requires her patients to have insurance. She cited an example of why: During a recent visit, one of her patients had a major heart attack. Mays called an ambulance and the woman was rushed to a local emergency room where she was treated and later recovered.

“If she hadn’t had insurance, that would have been a sticky wicket,” Mays said

Mays opened her own practice in 2008, after working as a preventive cardiologist at Tuality Community Hospital and developing a cardiac rehabilitation program at Oregon Health & Science University. 

Initially, she billed insurance but switched to a concierge practice in 2017 because she couldn’t make ends meet. 

“Insurance payments were really getting bad,” she said. “I would get checks for 9 cents.” 

She said it’s difficult to stay afloat based on office visits alone.

“This is what happens when you don’t do procedures,” Mays said. “Hospitals make their money on procedures. They don’t make it on office visits.”

For patients, it means paying the fee on top of insurance premiums and any copays. It’s unclear whether that increases their overall cost for care. A 2023 study of concierge practices that also billed Medicare, the federally backed insurance for seniors, showed that health care costs rose after physicians started charging a membership fee. 

But other studies have indicated that concierge medicine can lower costs, especially emergency room visits. A 2015 study found a more than 50% reduction in visits to emergency rooms and specialists offices along with a similar reduction in surgical procedures and X-rays, CT scans and MRIs.

That study found that primary care visits more than doubled, indicating that a greater use of lower-cost primary care can reduce higher-cost emergency and specialty services.

Analysts say more studies are needed to determine the impact of concierge medicine on the overall health care system, including on equity and overall access to needed care.

For now, surveys indicate it is associated with greater physician satisfaction.

Docs cite fewer headaches

Primary care physicians in traditional “fee-for-service” practices usually have a caseload of more than 2,000 patients. That compares with about 400 to 600 for concierge docs. With fewer patients, they can spend more time with each individual. And not taking insurance means less paperwork. 

“In an insurance-driven model, at least 40% of our time was spent doing these legal documents, the medical notes, and making sure that all of the codes and all of that stuff was correct,” said Dr. Nicholas Jones, who left an Optum-owned practice, Oregon Medical Group in Eugene, in 2023 to start a fee-only practice, Clear Health Direct Primary Care.

Ditching insurance saves practices money, he said.

“I don't need a billing department. I don't need a coding department,” he said. “A patient plugs in credit card information or a banking account and they get a straightforward, transparent, clear price every single month for the services that we render.”

The paperwork burden is often cited by disgruntled physicians as a cause for burnout. It also frustrates patients who complain their doctor spends visits typing on a computer.

Chris Pryor, a 73-year-old with Medicare, the federally backed health insurance for older people, switched with his wife about a year ago to Jones’ clinic. They’d been longtime patients of Oregon Medical Group but after it was bought by Optum in 2020, doctors started leaving. The couple became frustrated waiting months for appointments and being bounced among doctors.

Pryor says his $99-a-month membership fee saves him money and frustration.

“If I would go to a regular doctor on my health insurance, my copay might be anywhere from $10 to $40. A couple of visits to the doctor, you've covered the monthly fee,” Pryor said.

He said the model resembles how primary care used to be.

“You could get in to see the doctor,” Pryor said. “The doctor would spend time with you and get to know you. And so they didn't have to start from zero every time they wanted to see you and treat something.”

Though they have fewer patients, concierge physicians say they make as much or more than they made before.

“I don't pull down the big figures, but I make a better living than I made with 2,200 patients on the bus,” Mays said.

New law could help docs, patients

In Eugene, Jones has championed concierge practices that don’t take insurance, holding quarterly sessions for doctors to meet and discuss ways to start or improve their businesses. He also spearheaded House Bill 2540, which sailed through the Legislature this session with unanimous support. The law will allow a patient to pay cash for a service deemed medically necessary and covered by insurance, such as an MRI, and apply that to their in-network deductible if the cash price is less than the insurance rate.

The law also will lower administrative burdens from insurers and physicians, Jones said.

“I know I can do everything for a patient for cash cheaper than the insurance company,” Jones said. “We can get volume benefits through group purchasing organizations and don't need to have these lengthy contracts and unnecessary burdens of administrative tracking and data and all this other stuff.”

The bill takes effect in January along with another provision passed by Republicans in Congress in the mega-tax bill. It will allow patients to use health savings accounts, which are associated with high-deductible insurance plans, to pay the membership fees charged by physicians who don’t bill insurance.

Dr. Jeff Davenport, a concierge physician in Oklahoma and president of the DPC Alliance, which supports direct primary care practices, said the federal provision is likely to fuel a growth in these practices.

“It'll help employers provide this for their employees,” he said.

But he said concierge physicians need to be careful to retain control over their businesses. 

“We're gonna have a lot more corporate entities jumping in,” he said.

Attracting employers has been a longtime goal of Baskin, one of the first concierge physicians on the West Coast. He hoped to eventually work with employers. He contacted about 75 in the Portland area, offering them a corporate rate. But only a few companies have signed up, including Pacific Seafood and the Old Spaghetti Factory.

“They're mostly smaller companies and they represent a relatively small part of our business,” Baskin said. 

He’d like to see concierge practices work with federal insurers, like Medicare and Medicaid, which provides health coverage for 1.4 million low-income Oregonians — a third of the state’s population. 

“We would love to work with larger agencies that pay for health care,” Baskin said. 

For now, concierge practices are likely to remain in the minority, mainly serving those with extra income. But until federal policymakers and health care leaders make changes to better support primary care physicians and other providers, more doctors will continue to switch to concierge, retainer or direct care, physicians say. 

That leaves fewer doctors in traditional medicine to cover an ever older and sicker patient population.

“Most doctors say they wouldn't do it again,” said Mays, the preventive cardiologist. “I would have said that several times in my career, but now I actually love what I do.”

More in this series:
Part II: Concierge docs: As direct care clinics proliferate, debate continues
Part III: Why two physicians in Eugene are leaving PeaceHealth to create direct care practices