Concierge and direct primary care are booming, but corporatization and access questions are close behind

Concierge medicine and direct primary care have surged from the margins into a fast-growing slice of the primary care landscape, according to Oregon Health & Science University physician-researcher Jane Zhu, M.D., whose team used web-based directory data linked to national clinician records to track the expansion.

In an interview with Physicians Practice, Zhu describes rapid growth in the number of practices and clinicians participating in membership-based models alongside trends that complicate the “independent medicine” narrative, including a sharp rise in corporate ownership, a growing role for advanced practice clinicians, and a sizable share of practices that still bill Medicare. Zhu also flags bigger system-level questions that research is only beginning to answer: whether these models expand overall primary care capacity or simply reallocate it, how geographic clusters may reflect market demand and access pressures, and how policy changes such as expanded use of health savings accounts for membership fees could accelerate adoption while widening gaps for patients who can’t pay.

The following transcript has been edited for clarity and length.

Physicians Practice:So just to get started, Doc, tell me about the study. What did you find out?

Jane Zhu, M.D.: So just by way of background, I’m a primary care physician and a health services researcher as well. And as a primary care physician, I’ve been hearing a lot about interest in these new models of care: concierge medicine, which has been going on for quite some time, and then direct primary care, which is often sold as a way for physicians to take medicine back; to have more autonomy, to be able to dictate their own schedules, to have more stable revenue and to have greater access and attention for patients.

And so, what my team and I did was we used novel web-based directory data. We linked that to national clinician-level data, and we derived a sample of concierge and direct primary care clinicians. And essentially what we found was that between 2018 to 2023 there was a lot of growth in our sample of these practices. This is not a national census by any means, and we’re likely underestimating the true number of these practices and the involved clinicians, but we found that the number of concierge and direct primary care practices grew by over 80%, and the number of clinicians participating in these models grew by just as much. So that was pretty rapid growth that we’re seeing in a short period of time.

Physicians Practice: So, over that same five-year period, you found there was a 576% increase in these models that were becoming corporately owned. The big pitch for it is always that this is a way to save independent medicine. Is corporatization threatening the autonomy doctors are looking for by getting into these structures?

JZ: Definitely. I was surprised by that finding in particular because, as you mentioned, concierge and DPC practices are sold as a way to offer benefits to clinicians; smaller patient panels, reduced administrative burden, greater autonomy, all these positive things. But at the same time, if we’re also seeing rising corporatization and ownership in these models themselves, that can directly take away from some of the benefits of these models.

So, I think, as these models grow, we really need to focus on how they respond to the foundations of clinical care, and whether this ownership shift itself could run counter to those principles that are driving these models in the first place. That’s worth monitoring over time.

Whether corporatization is actually threatening these models is less clear. As I mentioned, our sample is probably not comprehensive of every single practice. But given that there’s such increased growth, I think that’s definitely cause for concern and really requires monitoring.

Physicians Practice: So, we’re seeing a shift where the share of physicians is actually declining, while advanced practice clinicians are now making up over 40% of the workforce in these models. Is concierge care moving away from the solo doctor ideal toward a corporate, team-based strategy?

JZ: It’s a great question. In our sample, there are actually solo advanced practice provider practices as well. But I think the trend we’re seeing, a greater share of advanced practice providers making up the composition of these practices, is simply a reflection of trends that are happening in the broader health care system.

We’re seeing similar things in academic medical centers and hospital- and health system-owned facilities, where a lot of frontline clinicians are increasingly comprised of advanced practice providers like nurse practitioners and physician associates. In some ways, that’s a response to broad workforce shortages. So, in that sense, what we’re seeing in the data around concierge and DPC practices isn’t that different from what we’re seeing across the health care system.

Physicians Practice: A large share of these doctors is still billing Medicare, which is not necessarily how these practices are pitched — breaking the chains of Medicare. Is that indicating that most doctors are finding it financially hard to fully opt out of that insurance system?

JZ: So, just taking a step back: in terms of the way these models often operate, concierge practices are a little bit different from DPC. They often offer similar benefits to patients and similar benefits to physicians. But the key difference is that concierge models charge membership fees, typically on the order of $3,000 to $5,000, sometimes even more, per year; and they continue to bill insurance. So, this is not a model where you’re foregoing insurance altogether.

That’s in comparison to direct primary care practices, where patients are paying a monthly or annual fee, often much lower, on the order of $50 to $100 per month, and it’s often billed as much more affordable to patients. In those models, physicians do not bill insurance for routine primary care. They’re charging a set rate, which often includes unlimited visits. It may include simple procedures. It might include more direct access, asynchronous communication with your physician. But they are not billing insurance, and that’s the key distinction between concierge and direct primary care models.

In our study, we used Medicare billing as one way to distinguish between concierge versus direct primary care. So, we’re using that as a way to distinguish between practices that are likely concierge practices, where they’re still participating in Medicare, versus DPC practices. And what we see in our sample is about a 60/40 split: 60% of the practices in these models are concierge practices, that’s a proxy and an estimate, and 40% are direct primary care.
Physicians Practice: A portion, I believe 30%, of the physicians joining these models are walking away from large health systems or integrated networks. Looking at your data, what do you think is the biggest factor pushing them out of that traditional employment?

JZ: Our study didn’t specifically talk to clinicians, so this is based on extrapolated evidence and anecdotal evidence that’s out there. But often clinicians cite administrative burden, short visit times, and burnout in traditional primary care practices. As a primary care provider myself, I can attest to that personally.

When I see patients, I have administrative expectations in terms of how many patients I’m able to see. Sometimes our visit templates are as short as 15 minutes and as long as 30 minutes, but often that’s not enough time to give patients the attention that they need.

[Physicians in these models] can choose their own schedules. They dictate the length of their visits. They can decide exactly what sort of care they’re going to be delivering without administrative oversight from a manager. And I think that affects clinician autonomy, job satisfaction, and longevity in the field quite significantly.

Those are often sold as some of the key benefits for clinicians who are thinking about leaving traditional primary care practices in hospitals and health systems — or corporate-owned practices — and moving into these new models of care.

Physicians Practice: You found big clusters of these practices in Texas, California and Florida. In your opinion, is it being driven by the wealth of patients, or more about regulatory environments?

JZ: I think it’s a matter of demand and market opportunities and pressures. The rise of concierge and direct primary care models is reflecting real needs — simple demand in the market — that people are willing to pay for more personalized care and better access.

Part of the reason we might see concentration in certain states is because there is greater population-level need in some areas. States like Texas and Florida have a higher share of older adults who are needing primary care and potentially lack access — and may have the means to pay for additional personalized care and access.

But there’s still so much that we don’t understand about these models. This is really quite new, particularly direct primary care. So, there could be regulatory and clinician-level factors, and there could be patient-level factors that push and pull. We don’t quite know right now.

What we see in other studies or research around where primary care practices, corporate practices, concentrate is similar: Texas, Florida, places where there’s demand for care.

Physicians Practice: You noted there were very few physicians moving into these models from community health centers. As concierge care and DPC expand, are we going to see a widening gap in access for patients who need primary care the most?

JZ: As I mentioned before, there are clear benefits to patients from these models. But what’s really unknown right now is the implication for systemwide access, and that’s uncertain. It probably varies by market and by the particular model.

What we worry about is unintended spillover effects. If these models are growing and drawing clinicians away from the traditional primary care system, and these clinicians are seeing fewer patients on average, then a key question is: while they expand, do they ultimately increase overall primary care capacity, or are they reallocating care toward patients who are able to access these models and have the means to pay, particularly concierge models, or to have supplemental coverage with direct primary care models?

One key element here is that there are important models of care that already exist: federally qualified community health centers, community primary care centers. If we’re focused on improving access and primary care capacity at a system level, we should be simultaneously making sure we invest in those other systems, our safety-net systems, so that access to care is maintained nationwide and across populations.

Physicians Practice: A connected question: According to your study, you found that many advanced practice clinicians are getting into these models as their very first job. Are new graduates skipping traditional primary care altogether? And what does that mean for the future of the workforce as a whole?

JZ: In our study, we found that about a fifth to a quarter of physicians entering had no prior employment. And among those with graduation data, about 70% were within three to nine years of medical school graduation, so they were fairly new; suggesting early-career interest in some of these models, and certainly that has implications.

I think there is a hunger from younger physicians to have alternative modes of practice. Right now, we’re at a stage where over 80% of physicians are employed by hospitals and health systems and by corporate entities. That’s a shift we’ve seen in the past 20 to 30 years.

In the past, physicians entering practice out of school were really able to enter independent practice environments, be their own business owners, be their own boss, and those opportunities have really dissipated with changes in the health care landscape. So, in our study, we’re seeing interest from newly graduated clinicians, which suggests this is something younger clinicians are increasingly looking at as a career opportunity.

Physicians Practice: You highlighted that the “One Big Beautiful Bill Act” put more emphasis on health savings accounts, and I believe it included the ability to pay for DPC or concierge through those tax-incentive accounts. How much do you think federal policy is going to accelerate the shift toward membership-based medicine in the next couple years?

JZ: So, substantially: I think federal policies and state policies create incentives for people to enter into these sorts of practices and for these practices to grow. In the past, it was not readily available for people to use their health savings accounts to pay for membership fees associated with these models. Now it’s a possibility — you can use your HSA to pay for this as a medical expense.

I think that will expand participation in these models, both by clinicians and by patients. The key question is whether the expansion of these models at scale will meet those demands — and again, what will be the spillover effects, the unintended consequences for those who don’t have access or can’t access these models? That’s something we need to monitor closely.

But overall, policies matter. Policies drive behavior. They drive incentives. And I think given that there is so much interest from policymakers in these models as a way to expand primary care access and give people the personalized attention they’re demanding, we ought to be focusing our research and building empirical evidence on these models of care.

We don’t have very much empirical evidence currently in terms of costs of care, ultimately to patients. In direct primary care models, they are not billing insurance for primary care. But patients don’t operate in a vacuum. They need primary care, but what happens if you need emergency room care? Or what happens if you need to go to the hospital and be admitted? You still often need insurance to cover those services.

So, lots of gaps in knowledge exist. We’re going to see a push to expand these models, and I think the research needs to follow suit and monitor closely, to be able to provide evidence for that expansion.

Physicians Practice: All right, that’s all the questions I have for you. Is there anything else you want to add, or anything you think I’m overlooking?

JZ: I appreciate the opportunity to talk about our research. As I mentioned, there’s a very good reason why these models have expanded. I think they offer a lot of positive benefits for both patients and clinicians.

What we need to monitor are the systemwide implications as the models expand — and understand a little bit more about how they might affect primary care capacity and access for populations that can’t yet access these practices.