Editor’s note: This is the second 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. Read the first installment here.
Chris Pryor no longer worries about getting a primary care appointment: He contacts his physician directly and can see him within a day.
Pryor, a 73-year-old in Eugene, pays $99 a month for that access, and it includes all of his primary care needs.
“I can have a visit with my doctor, whether it's on the phone or by email or by text, and get all the information I need to proceed with whatever care I need quickly and easily,” Pryor said.
Pryor is among an increasing number of patients who pay a fee to see a primary care physician. These physicians see far fewer patients than doctors who only take insurance, perhaps 500 patients compared to more than 2,000.
That means they have more time for patients.
But critics say practices that require a membership fee create a two-tiered medical system that favors richer people and worsens the primary care shortage by leaving some patients without a doctor.
Direct-pay practices vary in how they’re structured, what they offer and even what they’re called. Practices that only charge a fee and don’t bill insurance are called “direct primary care” or “retainer” medicine. Others use the term subscription or membership-based care. Like many experts, The Lund Report is using “concierge” care as an umbrella term to refer to all these variations, though some in the industry reserve that term for practices that charge a fee and bill insurance.
The trade publication Concierge Medicine Today estimated in 2023 there were 12,000 practices in the U.S. that charge a fee and bill insurance. An organization that tracks fee-only practices estimated there are nearly 3,000 of them nationwide.
In Oregon, the Department of Consumer and Business Services has certified about 50 providers who only charge a fee. They’re mostly in urban areas though they’ve also emerged in Astoria, Enterprise, Hood River and Grants Pass.
The most exclusive practices charge $25,000 a year, but they’re in the minority. Most direct care or retainer practices charge up to $50 for a child and $100 for an adult, according to a study by the American Academy of Family Physicians.
Still, that creates an inequity, critics and researchers say. Primary care practices that don’t bill insurance don’t cover hospital expenses or specialist care. They advise patients to also get insurance, which means they pay the doctor’s fee as well as copays and premiums associated with their policy.
Though many Medicare patients, like Pryor, use direct primary care practices, the membership-based or subscription practices are typically not accessible to the lower-income earners.
“People who have more resources are able to get greater access,” said Adam Leive, a health economist at the University of California, Berkeley and lead author of a study on concierge medicine.
“But I wouldn't go so far as to say it's unethical,” he added. “It's unethical as far as capitalism is unethical.”
Oregon patients face longer waits
Insurers and Medicaid organizations are required by law to maintain a network of providers that’s large enough to serve its patient populations. But a lack of government enforcement has led to frequent complaints of “ghost networks” — meaning patients who try to get appointments spend hours on the phone only to find that many providers have retired, moved or stopped taking new patients.
Anyone who’s tried to see their primary care doctor recently knows it can take months or longer to get an appointment — and that’s for existing patients.
In one high-profile example, Oregon Health Authority Director Dr. Sejal Hathi told The Lund Report she initially faced a wait of 13 months for a primary care appointment after she moved to Oregon.
At Providence Health & Services, patients wait up to six weeks to see a new physician, said spokesperson Gary Walker. Legacy Health did not respond to a question about its primary care waits but its website shows most of its primary care physicians are fully booked.
“We have a crisis with primary care in this country,” said Guy David, who worked with Leive on the concierge study and chairs the Health Care Management Department at The Wharton School of the University of Pennsylvania. “It’s kind of important because a lot of the dollars that accrue in the health care system start in primary care. And primary care is really where good prevention can actually take place.”
In Oregon, the number of full-time primary care physicians increased about 10% between 2016 and 2024, from nearly 4,240 to more than 4,680, according to Oregon Health Authority data. And in 2022, federal data indicated that Oregon had nearly 104 primary care physicians per 100,000 residents, one of the highest ratios in the county.
But some question whether the state’s data reflects the situation on the ground. A 2023 national survey by the Commonwealth Fund used to assess primary care access ranked Oregon 44th among states in the number of adults who have a regular provider. And a 2022 survey by AMN Healthcare, a physician search firm, found that Portlanders waited about 40 days to be seen as a new patient by a primary care physician — the longest delay among 15 metro areas in the country, and about double what people experienced in the other cities.
As a wave of providers reaches retirement age, experts don’t expect relief anytime soon.
“We know that demand for primary care in Oregon currently exceeds available providers, and we generally expect demand to grow in the future as our population ages,” Franny White, a health authority spokesperson, said in an email.
Richer, whiter patients
The long waits for care have spurred patients like Pryor to switch to a concierge practice. It’s unclear how many people have done the same and what the impact has been. Research on the sector is lacking.
One study, published in 2005 in the Journal of General Internal Medicine, surveyed more than 230 traditional physicians and more than 80 who charged a fee. It found that concierge practices served a whiter and higher-income patient population, potentially exacerbating existing health care inequities.
“Given that minorities are already underserved and at risk for worse health outcomes, our findings suggest that retainer practices could contribute to tiering of health care and to disparities in health care according to race as well as wealth,” the study said.
Another study, published two years ago in the Journal of Health Economics by Elsevier, was more extensive and reached a similar finding about income. The study looked at nearly 820 physicians who switched between 2008 and 2021 from a traditional practice to a concierge clinic that billed insurance. Medicare claims of tens of thousands of their patients showed that those who followed the physicians after they opened a concierge practice lived in richer areas.
“There was a very strong positive relationship between the likelihood of joining the concierge practice and the income of the ZIP code,” said Leive, the study’s lead author. “We didn't find the decision to join concierge medicine was related to the person's health status.”
Leive said concierge practices aren’t necessarily hurting the poorest: They have Medicaid, which provides free dental, physical and mental health care to low-income people. About 1.4 million people in Oregon are covered by the federally and state-funded Oregon Health Plan.
The rich can pay for what they need. That leaves the middle classes.
“They're perhaps the ones who are suffering this primary care shortage the most because of concierge practices,” Leive said.
Several direct primary care physicians told The Lund Report they try to keep their rates affordable enough to be appealing even for patients enrolled in Medicaid. All of them said they offer discounted or free care to some of their patients to not leave poorer people behind. They’re not required to do so, but the trade group, the DPC Alliance, recommends that direct primary care physicians provide some charity care.
Effect on costs, system debated
Besides being out of reach for many patients on tight budgets, concierge practices that bill insurance can increase costs, Leive’s study found. A year after switching, the health care spending by their patients was 25% higher than those who stayed with a traditional provider.
But concierge practices that don’t bill insurance can decrease costs, according to a paper published in 2020 by the Society of Actuaries. It found a drop in spending at a company that offered employees the choice between a direct primary care clinic and a traditional practice.
It found a nearly 13% decline in demand for health care services among the direct primary care patients, and they used the emergency department about 40% less.
Neither study tracked overall health status. The 2023 paper, however, found no difference in mortality among the two groups of patients.
Critics say when a physician leaves a traditional practice that depends on insurance payments, some of their patients are likely left without a provider.
That’s what happened to Pryor in Eugene. He was a patient of the Oregon Medical Group for more than 40 years. Most of that time it was owned by the physicians. But in late 2020, it was purchased by Optum, a subsidiary of UnitedHealth Group, a giant national conglomerate.
Many physicians left. The clinic bounced Pryor among doctors and then last year said it didn’t have one for him.
The American Medical Association considers patient abandonment unethical. But what happened to Pryor wasn’t the physician’s fault, said Dr. Eric Wiser, a family physician Oregon Health & Science University who directs a center focused on bolstering health professionals in underserved areas.
He said the companies that employ the doctors, like Optum, are responsible for ensuring the continuity of patient care.
“My employer has responsibility for my patient,” Wiser said.
Trend offers lessons, some say
Concierge practices have created a divide among physicians, with some arguing their growth is a problem. A 2023 paper published in the AMA Journal of Ethics by two physicians said the most exclusive practices are reinforcing the social divide and depriving poorer people of health care.
“VIP care disproportionately uses finite resources, as the increased resources allocated to the wealthy deplete the resources available to other patients,” the paper said.
These days primary care clinics struggle to recruit doctors. That means when one leaves a practice, those who remain might have to see even more patients.
Burnout is a major problem among primary care doctors, said Betsy Boyd-Flynn, executive director of the Oregon Academy of Family Physicians.
“I think it's a little better than it was during COVID,” Boyd-Flynn said, “but I think it's about to get worse as Medicaid becomes more complicated and funding is cut, and physicians are going to be left to try to wrestle with harder problems with fewer resources.”
Her members are divided over concierge medicine.
“Some of my members are very passionately opposed to it,” she said. “Some of my members (say) this is the way medicine should be practiced.”
She said concierge practices resemble what primary care used to be decades ago, when doctors had a personal connection with their patients and offered much longer appointments than those that are typical today.
“But if everybody did it, our situation would be even more dire,” she said.
But Oregon doesn’t have enough providers and insurance rates are not high enough to ensure long appointments for everyone.
Boyd-Flynn doesn’t blame physicians who leave traditional practices. If they didn’t, many would no longer be practicing medicine, she said.
“I'd rather have them taking care of people,” Boyd-Flynn said.
The profession should learn from them, she said.
“We should be taking a really hard look at why this is so attractive, and what we can be doing to fix primary care to make it more like that and less the grind that it currently is,” Boyd-Flynn said.
Proponents, like Dr. Nicholas Jones, who cares for Pryor at his Clear Health Direct Primary Care clinic in Eugene, see practices that don’t bill insurance as the future. He says insurance should only be used for big, unexpected expenses, like heart surgery or cancer treatment, not for everyday needs.
In directly paying a physician, patients have more buy-in and are more likely to follow their advice, he said.
“You also have a model where the medical team that's caring for patients is rewarded by getting them healthy and keeping them healthy, as opposed to the traditional way where the more patients per day that you see,” Jones said, the more you get paid.
But until employers and federal and state governments work with concierge providers, they’re unlikely to become the majority, experts say.
David, who chairs The Wharton School’s Health Care Management Department and worked on the concierge study, said that model could help fix the broken primary care system in the U.S.
But instead of serving people with higher incomes, it should cater to the sickest, he said.
“We have created these exclusive vehicles that exacerbate the primary care shortage and we're using those vehicles for the wrong people,” David said. “Not everybody needs this level of attention. How about if we create a vehicle within society that allocates people based on their needs as opposed to based on the means.”
Wiser agreed there are lessons in fee-based medicine.
“Maybe we shouldn't have 50 insurances,” he said. “Maybe we shouldn't have an entire workforce that's dedicated to billing and recouping money from the health insurance company,” he said. “There are definitely some lessons to be learned from it that we can apply to our current primary care system to make it work better.”
More in this series:
Part I: “Concierge docs: Oregon physicians switch to retainer payments amid primary care shortage”
Part III: Why two physicians in Eugene are leaving PeaceHealth to create direct care practices
There is another side to this issue that is commonly ignored, but stems from the same problems that created the primary care mess: if you have to shorten visits to meet the patient volume, you will just kick the can down the road. I see referrals from "providers" every single day that lack evaluation and treatment of common primary care disorders. Instead, due to lack of time, administrative burdens and poorly trained nurse practitioners the assessment and plan simply states "Refer". This is massively important in that it delays evaluation and treatment, fills up specialists and causes more delay to see them at higher expense. We are hiring PAs to do the primary care we are sent. So in essence, whatever the mechanism to pay more to PCP to spend more time with each patient...it saves money overall. I believe there have been studies since the 1990s supporting this simple issue.