Fee-Based Primary Care Is Hastening Doctor Shortages In The US

The number of concierge and direct primary care practices are rapidly rising across the United States, highlighting a fundamental shift in how Americans are receiving primary medical care, a new study finds.

This article was written by John Hopkins University and originally published by Futurity.

These emerging models, which charge patients annual or monthly fees for enhanced services, have grown in popularity over the last five years, potentially improving care for those who can afford it but raising broader concerns about access to care for the general public.

Between 2018 and 2023, the number of concierge and direct primary care practices nationwide surged by 83.1%, and the number of clinicians working in them increased by 78.4%, according to a study conducted by researchers from the Johns Hopkins Carey Business School, the Johns Hopkins Bloomberg School of Public Health, Oregon Health & Science University, and Harvard Medical School.

The findings appear in Health Affairs.

Both models offer more personalized care, greater availability, and smaller numbers of patients per provider. Concierge practices, however, charge an annual retainer fee, which can range from a few thousand dollars up to tens of thousands of dollars, all while continuing to bill existing health insurance for office visits and procedures. Direct primary care, or DPC, practices typically charge a smaller monthly or annual fee but operate entirely outside of the insurance system.

“The growth of these models may benefit participating patients and clinicians, but it’s important everyone understands the potential impact these practices have on the health care system at large,” says Dan Polsky, coauthor of the study and a professor with joint appointments at the Carey Business School and the Bloomberg School. “We have to consider how the growth of these models may affect access to primary care for the vast majority who can only afford the care covered by their insurance plan.”

The study analyzed a substantial national sample of more than 6,000 concierge and DPC models over a six-year period. During this time, the number of practice sites grew significantly, from 1,658 practices in 2018 to 3,036 practices in 2023. The number of individual clinicians working in these practices expanded from 3,935 clinicians in 2018 to 7,021 clinicians in 2023.

The widespread adoption of these membership-based models, which frequently target higher-income patients seeking enhanced services, like shorter wait times and longer visits, creates concerns about a growing general primary care shortage.

The rapid growth is fueled in part by primary care clinicians who are moving away from traditional settings, where health care workers often experience challenging workloads and increased risk of burnout. Clinicians report that these new models offer smaller patient loads and less administrative burden associated with insurance paperwork, which can lead to improved job satisfaction, prior research suggests.

However, as doctors move into fee-based practices, the researchers warn it could exacerbate the existing shortage of primary care physicians in traditional health care settings.

“Concierge and direct primary care models, in comparison to traditional primary care settings, offer clinicians smaller patient panels and increased clinical autonomy, which may improve job satisfaction and extend career longevity,” Polsky says.

“The increasing interest clinicians are showing in fee-based practices may be telling of certain pain points clinicians face in traditional primary care settings.”

While concierge and DPC models were traditionally run independently, the researchers also observed a substantial shift in ownership: corporate-affiliated practices grew by 576% during the study period.

This trend suggests that large for-profit companies are increasingly investing in these personalized care models, a development that will be important to monitor, according to the researchers, as corporate ownership may change the nature of care delivered even within these individualized settings.

In other words, benefits that attract clinicians and patients to these models, like less administrative burden, shorter wait times, smaller patient loads, and longer visits, may be altered by corporate influence. For example, corporate-affiliated models might charge lower membership fees and bill insurance while operating “at scale,” potentially changing the individualized nature of care that these practices have been traditionally known for.

“Our research draws attention to the rapid expansion of these models,” Polsky adds. “It’s our hope that by increasing awareness of the rise in fee-based practices, that we’re raising the necessary questions for policymakers to ensure that high-quality primary care remains available for all Americans.”

Source: Johns Hopkins University