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A new analysis led by researchers at Harvard Medical School’s Blavatnik Institute, Oregon Health & Science University, and Johns Hopkins University provides crucial insight into how the rapid growth in concierge and direct primary care (DPC) practices is transforming the market for primary care in the United States.
The researchers found that in just five years, from 2018 to 2023, the number of concierge and DPC practices grew by 83 percent and the number of clinicians in those practices increased by 78 percent. Moreover, while these practices value autonomy and independence, they are increasingly owned by corporate entities.
The study is the first broad, nationwide analysis of the size and characteristics of these new forms of primary care. The findings are published in the December issue of Health Affairs.
Concierge medicine and DPC are of growing interest to patients, clinicians, and policymakers.
Concierge practices provide personalized care and exclusive access, including same-day or next-day appointments, home visits, and often around-the-clock access by phone and email. Doctors still bill insurance and have much smaller numbers of patients. Membership fees can range from thousands to tens of thousands of dollars a year.
DPC does not deal with insurance. Patients pay for primary care services and common prescription drugs out of pocket, often at reduced prices. The number of patients per doctor is lower than in traditional primary care practices. Membership fees are often several hundred to thousands of dollars a year.
These alternative practice models provide an attractive option for physicians who are looking for more clinical autonomy, smaller patient loads, and less administrative hassle. They also provide better access to patients who can afford the upfront membership fees and out-of-pocket costs. However, due to physicians moving from traditional health care practices to these free-market models and the majority of patients who cannot afford to follow, they raise concerns about exacerbating primary care workforce shortages and inequities in access to care.
“It’s important to understand this growing segment of medicine, which many doctors and patients enjoy because of more face time together and faster, personalized access to care,” said study senior author Zirui Song, HMS associate professor of health care policy.
“It’s also important to consider what this expanding free market will mean for those physicians and patients who remain in traditional primary care practices, which increasingly face more patients needing new primary care doctors but fewer doctors to meet that need,” said Song, who is also a primary care doctor and HMS associate professor of medicine at Massachusetts General Hospital.
Song and colleagues used a combination of public and proprietary databases to get a picture of how concierge and DPC practices have evolved across the United States.
Song estimated that while concierge medicine and DPC practices likely make up between 10 and 20 percent of primary care physicians, it is difficult to know the precise scale because not all providers participate in the available databases and because membership fees and direct payments to practitioners don’t show up in health insurance claims data.
In addition to the growth the researchers reported, the study found that the nature of concierge medicine and DPC practices is changing in significant ways.
For example, advanced practice clinicians — nurse practitioners and physician assistants — increased from 23 to 40 percent of the workforce in these practices. And independent ownership of these practices fell from 84 to 60 percent, but there was a roughly six-fold increase in practices with corporate affiliations.
This last finding was particularly surprising, Song said, because autonomy and independence are primary motivators for physicians transitioning into concierge or DPC practice. Yet just as more doctors make this career shift, these practices are increasingly corporate-owned.
Authorship, funding, disclosures
Additional authors include Jane Zhu, Trisha Marsh, Daniel Polsky, and Aine Huntington.
This work was supported by the Agency for Healthcare Research and Quality (R01HS029467), the Commonwealth Fund, and the National Institute for Health Care Management Foundation.
