Primary Care — From Common Good to Free-Market Commodity

More than 30% of U.S. adults lack a usual source of primary care.1 As the population ages, the gap between primary care demand and supply is poised to widen. Primary care physicians (PCPs) are older than other physicians, on average, with many approaching retirement age²; meanwhile, less than one third of physicians graduating from primary care residency programs plan on practicing primary care.³ Often-cited culprits of this workforce shortage include burnout, administrative burdens, income disparities between PCPs and specialists, and loss of autonomy amid a shift toward increased ownership of physician practices by health care systems and corporations.

Increasingly, however, the shortage of PCPs is being exacerbated by another phenomenon: the evolution of primary care — long championed as a common good — into a private, free-market commodity.

Throughout the United States, PCPs have been leaving traditional practices for concierge and direct primary care (DPC) practices, in which patients are offered personalized and more accessible primary care in exchange for membership or retainer fees. The market for these services has grown rapidly. MDVIP, a concierge practice network founded in 2000, for which private equity firms serve as majority owners, reports having more than 1300 PCPs nationally caring for more than 400,000 patients. Given pervasive difficulty associated with finding a PCP, along with willingness among many patients to pay retainer fees, health care systems have also opened their own concierge practices, often alongside traditional primary care offerings. In addition, roughly 10% of family medicine physicians operate a DPC practice, with growing interest in this model.⁴ This burgeoning market has enabled self-insured employers to enter into contracts with DPC practices to provide care for their workers.

Concierge and DPC models have key differences. In concierge primary care practices, physicians offer more personalized, “exclusive” services than are generally provided in traditional practices. These services include same-day or next-day appointments, on-demand communication by phone or email, and sometimes, home visits or accompaniment to specialist appointments. Patients might not be charged copayments for primary care services, but physicians can bill insurers for the care they provide. In exchange for these services, patients pay a retainer fee, which can range from a few thousand dollars to tens of thousands of dollars per year.

This personalized access is facilitated by substantial reductions in panel size. Concierge practice panels generally include 400 (or fewer) to 600 patients, as opposed to 2000 or more patients in a typical primary care practice.⁵ Having smaller panels allows physicians to increase their face time with patients and gives them more opportunities to customize screening, exams, and treatment plans.

In comparison, most DPC practices operate entirely outside the insurance system, with patients paying a monthly or annual fee directly to their physician in exchange for a set of predetermined services. Yearly rates can vary widely depending on the practice, its offerings, and the population it serves — from roughly $500, for example, to thousands of dollars. These membership fees finance the fixed costs of running the practice and may also cover same-day appointments, communication by phone or email, and basic tests and in-office procedures, such as cryotherapy or joint injections. Patients pay out of pocket for other labs, imaging, and medications.

Physicians in DPC practices may enter into group-purchasing agreements with other physicians or negotiate directly with vendors over prices. Out-of-pocket costs for patients can be as low as $50 for a chest x-ray, $1,200 for a colonoscopy, and $40 to $60 — or as little as a few dollars — for a blood test. Patients may pay less in cash than they would for insurance premiums and cost sharing combined. Generic medications may be dispensed by wholesalers or mail-order pharmacies, bypassing pharmacy benefit managers. For emergency department visits, hospitalizations, and specialist visits, patients can submit bills to insurers, with many people being covered by high-deductible, wraparound policies for emergencies. Panel sizes in DPC practices tend to be slightly larger than those in concierge practices^4,5 — but still substantially smaller than traditional primary care panels. In some practices, features of concierge medicine and DPC coexist.

Physicians in these practices have emphasized the power associated with “taking primary care back” after leaving previously unsatisfactory roles that made them feel like gatekeepers and paper-pushers. Indeed, these models can offer physicians notable advantages over traditional primary care models, including greater clinical autonomy, more take-home pay, and improved work–life balance and job satisfaction.^4,5 Less burdened by prior authorizations, insurance denials, billing and coding tasks, and other demands in traditional practices — including the need to adhere to regulatory requirements under alternative payment models — physicians often have more time for direct patient care. Practice-management costs can also be lower than those in traditional primary care, given reduced administrative workloads. These benefits could encourage some PCPs to extend their careers.

Concierge and DPC practices also have advantages for patients receiving care under these models, including improved access, shorter wait times, longer visits, and more personalized care.⁵ Advocates of DPC have noted that many of these practices accept lower-income patients, older adults with fixed incomes, and patients with complex medical issues, although information on patient selection is lacking. Some have argued that the accessibility of primary care under concierge and DPC models might help reduce emergency department visits and hospitalizations, but data in this area are also scant.

Despite their benefits for participating physicians and patients, these private, free-market primary care models invoke important trade-offs for society as a whole. First, as concierge and DPC markets siphon off physicians — bringing with them patients who can afford the membership or retainer fees — physicians and patients remaining in traditional primary care face heightened constraints. With panels reduced by 80% or more, a single full-time physician’s departure from traditional primary care for a concierge or DPC practice could mean that roughly 2000 patients lose their PCP. Although practices generally try to reassign patients to other PCPs, those physicians — who often already have full panels — cannot easily take on new patients. Moreover, this increased strain may push them closer to exiting traditional primary care, creating a cycle that poses fundamental concerns for the sustainability of primary care, particularly in the absence of other clinicians filling primary care roles or growth in the pipeline.

Second, membership fees for concierge and DPC practices are left to the discretion of practices and are dictated by what the market will bear. High fees could solidify a tiered system for primary care access, grounded in existing income and wealth inequality. Furthermore, these fee systems introduce perverse incentives for practices to enroll healthier patients with fewer health care needs — analogous to payment structures involving capitated payments without risk adjustment, under which savings associated with caring for healthier patients can translate into higher profits. Although practices can charge lower-income people lower fees than higher-income people, the extent to which they prioritize medically underserved patients is unknown.

The rise of concierge and DPC practices may also complicate the shift toward alternative or value-based payment models in the United States. Under value-based contracts, patients are attributed to the health care organization in which their PCP practices. Organizations are then held financially accountable for spending and quality of care, typically devoting staff to monitoring and helping clinicians improve performance on quality measures, including primary care measures focused on cancer screening and chronic-disease management. DPC and concierge physicians who don’t accept insurance aren’t governed by these contracts or reporting requirements. Lack of reporting requirements reduces administrative burden, but it also diminishes accountability — leaving patients (who serve as consumers in these markets) as the sole arbiters of quality of care.

As access to primary care narrows nationwide, exit ramps toward the free market are widening. Physicians taking these off-ramps may find higher incomes and restored joys of practice. Patients who can afford membership fees for concierge or DPC practices may also benefit from these models. Yet trade-offs — in the form of decreased access for patients and increased strain on PCPs in traditional primary care — are borne by the rest of society. Primary care’s shift from common good toward free-market commodity increases the urgency for payers and policymakers to strengthen traditional primary care practices, even as newer models take hold. For individual patients and physicians, this shift also provokes deeper questions about what it means to have a primary care doctor — and to be one.