Direct Primary Care vs. Concierge Medicine
A Second Anchor for the Independent Primary Care Practice
Rich Powers, Co-Founder and Managing Partner and Katherine Maruyama, Partner, Accretive Health Advisors | September 2026
Last week, Accretive Health Advisors was proud to sponsor and exhibit at the Colorado Medical Society's 2026 Annual Meeting, held September 18 and 19 at The Lodge at Vail. The Colorado Medical Society is the largest organization of physicians in Colorado, with more than 6,000 members across all specialties and practice settings.1 It was a great event and was also Oktoberfest in town which made for a fun atmosphere around Vail. The program opened with Dr. Tracee Metcalfe, a Vail physician and the first U.S. woman to summit all 14 of the world's highest mountains, and it featured sessions on physician well-being and on the role of the physician in the age of AI.2
The conversations at our booth were just as telling. We came to Vail to talk about payor contracting and price transparency data (the slick we handed out was titled "Maximize Your Reimbursement Power"). Several of the primary care physicians who stopped by, however, had already walked away from payors entirely. They were running Direct Primary Care practices that do not take insurance at all, one of them with more than 400 members. Others were running a hybrid, keeping some insurance contracts while building a membership base alongside them.
Those conversations raise a question every independent primary care practice should be asking: what role should a prepaid membership model play in your business? Is it a replacement for payor contracts, a hedge that strengthens your hand with payors, or a cash flow engine that steadies the practice? Our answer is that it can be all three, and that is the focus of this article.
Two Models That Often Get Confused
Direct Primary Care (DPC). The American Medical Association describes DPC practices as practices that do not accept health insurance or bill insurers. Patients instead pay a monthly membership fee that covers their primary care services, sometimes including labs or basic imaging.3 Typical DPC fees run $50 to $100 per month for adults and $20 to $50 per month for children, based on American Academy of Family Physicians data cited by the AMA.3 The core promise is access: unlimited scheduled visits, longer appointments, and direct contact with the physician. Because DPC covers only primary care, patients still need insurance for hospital, specialty and emergency care.4
Concierge Medicine. Concierge medicine (sometimes called retainer medicine) looks similar from the patient's chair but works very differently on the revenue side. Concierge practices charge an annual or monthly retainer for enhanced access, such as same day or next day appointments, home visits, and around the clock phone and email contact, and they continue to bill insurance for the medical care itself.5 The AMA's Code of Medical Ethics addresses these arrangements directly. Physicians may contract for "special non-medical services and amenities" with patients willing to pay out of pocket, but they must keep retainer fees clearly separate from services billed to insurance and deliver the same quality of medical care to every patient in the practice.6 Concierge fees are higher, generally $2,000 to $5,000 per year, with some programs reaching $20,000.4
Put simply, DPC replaces the payor. Concierge sits on top of the payor. That difference drives everything else, from how you bill to how you treat Medicare patients.
| Direct Primary Care | Concierge Medicine |
Bills insurance? | No (pure DPC); hybrids bill for some patients | Yes, for covered medical services |
What the fee buys | The primary care itself | Enhanced access and amenities, not covered care |
Typical fee | $50 to $100 per month (adults) | $2,000 to $5,000 per year |
Medicare | Physician typically opts out and uses private contracts | Can stay enrolled; fee cannot buy Medicare covered services |
HSA payment (2026) | Yes, up to $150 per month individual / $300 family | Only if the arrangement meets IRS rules |
Colorado law | Not insurance under C.R.S. 6-23-102 | Standard payor contract and billing rules apply |
Revenue profile | Predictable monthly PMPM, no claims | Retainer plus fee for service claims |
Both Models Are Growing Fast
A study published in Health Affairs in December 2025 by researchers from Johns Hopkins, Harvard Medical School and Oregon Health & Science University found that concierge and DPC sites grew 83% between 2018 and 2023, from 1,658 to 3,036, while the clinicians working in them grew 78%, from 3,935 to 7,021.7 Corporate affiliated practices grew roughly sixfold over the same period, and the share of these practices that are independently owned fell from 84% to 60%.7 In other words, investors have noticed this model. Independent physicians should notice it too, before the market is shaped by someone else.
The driver is no mystery. Physicians are tired of running on the fee for service treadmill which doesn’t keep pace with the costs of running a medical practice. One DPC physician told Becker's, "We cannot spend so much time seeing so many patients... to get an extra $17." A concierge internist in the same piece saw her panel drop from 1,700 patients to 800 after converting.8 Physician well-being was on the agenda in Vail for a reason.
However, these models do have critics. A widely cited JAMA Viewpoint argued that DPC may attract healthier patients and do little to lower overall costs.9 We take that critique seriously. A well designed program answers it with fair pricing, clear disclosures, and a plan for the patients who do not join.
Why Now: The Tax Law Changed in Your Favor
Until this year, a patient with a high deductible health plan who joined a DPC practice risked losing the ability to contribute to a Health Savings Account. The One Big Beautiful Bill Act fixed that. Effective January 1, 2026, an HSA eligible individual may enroll in a qualifying DPC arrangement and pay the periodic fees tax free from the HSA.10 Under IRS Notice 2026-5, issued December 9, 2025, the fee cap is $150 per month for an individual and $300 per month for a family, and the arrangement cannot cover procedures requiring general anesthesia, prescription drugs other than vaccines, or lab services not typically provided in an ambulatory primary care setting.11
That matters because the potential market is large. KFF's 2025 Employer Health Benefits Survey found that average family premiums reached $26,993, with workers paying $6,850 of it out of their paychecks, and that 29% of covered workers are enrolled in a high deductible plan with a savings option.12 Those patients are already paying for primary care out of pocket until they meet a deductible. A $75 monthly membership paid with pretax HSA dollars is an easy sell, and the same logic applies to local employers who want to contract directly with a practice for their workforce.
A Hedge Against Payors, Not Just an Exit
I spent nearly 25 years on the payor side at Humana, and I can tell you that a payor negotiates differently with a practice that can walk away. Climbers never trust a single anchor. Most independent primary care practices hang entirely from one: their payor contracts. When a payor holds rates flat for five years, the practice has nowhere to go. A membership program is a second anchor. It carries weight on its own, and it changes every payor conversation because the practice no longer needs any single contract to survive. There are three ways to set that anchor.
1. Full exit to DPC. This is the cleanest model and the hardest transition. Payor contracts must be terminated according to their notice provisions, patients need time to decide, and Medicare needs a decision of its own. A physician who opts out of Medicare files an affidavit, opts out for two year periods that renew automatically, and must sign a private contract with every Medicare patient. During the opt out period, Medicare pays nothing for that physician's services, directly or indirectly.13 Colorado adds a Medicaid wrinkle: DPC providers are subject to C.R.S. 25.5-4-301, which bars private contracting with Medicaid patients for Medicaid covered services.14
2. The hybrid. Keep the payor contracts that pay fairly, exit or renegotiate the ones that do not, and build a DPC membership for uninsured patients, HSA holders and local employers. This is where most of the physicians we met in Vail are headed. It works only if you know which contracts are worth keeping, and it requires a careful read of each payor agreement, since many contain provisions that limit what a practice may charge a plan's members for covered services. Some physicians at our booth told us payors have pushed back on network PCPs who also run DPC programs. Read your contracts before you assume either way.
3. The concierge overlay. Stay in network and add a retainer for enhanced access. For Medicare patients, CMS has taken the position that membership fees are permissible only if they are not additional charges for items or services Medicare already reimburses.15 The AMA's ethics guidance draws the same line.6
This is where Accretive does its best work. Our price transparency data shows exactly what each payor pays your peers, by code and by market, so you can see which contracts are worth keeping and which ones are holding you back. Every model above starts with that answer.
The Cash Flow Case for PMPM
The most underrated feature of a membership model is not the fee. It is the timing. A per member per month (PMPM) fee is collected at the start of the month, before the care is delivered. There are no claims to submit, no denials to appeal, and no receivables aging for 45 days. Consider a few illustrative scenarios (before operating costs and member turnover):
• Pure DPC: 600 adult members at $85 PMPM produces $51,000 per month, or $612,000 per year, collected in advance.
• Hybrid: 250 members at $75 PMPM adds $18,750 per month, or $225,000 per year, on top of existing insurance revenue.
• Concierge overlay: 300 members at $2,500 per year adds $750,000 in annual retainer revenue while the practice continues to bill insurance.
Even Medicare is moving primary care in this direction. The CMS Innovation Center's ACO Primary Care Flex Model, which runs from 2025 through 2029, pays participating ACOs a prospective monthly primary care payment designed to shift primary care "away from fee-for-service, visit-based payment to a flexible, predictable revenue stream."16 When Medicare itself pays primary care by the month, the membership model is no longer on the fringe.
The model is not without risk. The AMA notes that DPC physicians may earn less in the early years while they build a panel, and that recruiting members takes real work.3 Pricing, panel size and churn have to be modeled before the first payor termination letter goes out.
What the Patient Gets
The business case matters, but the patient is the reason this model is growing. Consider what it takes to see a primary care physician in an insurance based practice today. AMN Healthcare's 2025 survey of 1,391 physician offices across 15 major metro areas found that a new patient seeking a physical from a family medicine physician waited an average of 23.5 days, up 14% since 2022. Across all six specialties surveyed, the average wait reached 31 days, the longest since AMN began the survey in 2004.17 Denver is worse than the national picture. The average wait for a new family medicine patient in the Denver metro was 39 days in 2025, nearly double the 21 days recorded in 2022, and the longest wait quoted by a Denver office was 140 days.17
The membership model is built to close that gap. In the AAFP's survey of DPC practices, 99% include same day appointments in the membership, along with phone, text and telemedicine access, and the average panel is 413 patients.18 DPC physicians in that survey handled more patient contact by phone or text each week than in the exam room. Compare that with a traditional fee for service practice, where an analysis of roughly 21 million primary care visits found the average exam lasted about 18 minutes.19 The concierge internist quoted earlier cut her panel from 1,700 to 800 for the same reason: time with each patient.8
Access is where quality starts. A physician with a smaller panel has time to manage chronic conditions between visits, answer a text before a small problem becomes an urgent care visit, and know the patient well enough to notice when something changes. That relationship is what many patients feel they have lost in primary care, and it is what they are paying for. The concierge patient buys the same access while the practice continues to bill insurance for the care itself. For the practice, a patient who can reach the physician is a patient who stays, and member retention is the number that makes every PMPM projection work.
How Accretive Helps You Build It
We help primary care practices design and launch membership programs that fit their market, their patients and their payor contracts. Working alongside your healthcare counsel, we:
• Model the economics: set membership pricing, panel targets and break even timelines using your own claims data, compared against what your payor contracts pay today.
• Review every payor contract: identify member charge restrictions, termination provisions and notice dates, then decide which contracts to keep, renegotiate or exit.
• Renegotiate the contracts you keep: use price transparency benchmarks to move below market rates toward the top of the market, with a credible alternative behind you.
• Map the Medicare and Medicaid path: evaluate opt out versus a concierge overlay, and build the right structure for Colorado's Medicaid rules.
• Structure member and employer agreements: align DPC agreements with Colorado's DPC statute and the new IRS HSA rules, and package direct offerings for local self-funded employers.
Accretive's clients have achieved a $129 million uplift in their annual revenue (over the prior two years) and a 5.5x ROI over that period, and 92% of our fees were performance based. We only win when you do.
If you stopped by our booth in Vail, we look forward to continuing the conversation. If you did not, let's start one. Visit accretivehealthadvisors.com to schedule a call with our team.
Sources
1. Colorado Medical Society, "About." https://www.cms.org/about/
2. Colorado Medical Society, "2026 CMS Annual Meeting Agenda," The Lodge at Vail, September 18 to 20, 2026.
3. Georgia Garvey, "Pondering direct primary care? 10 potential benefits and drawbacks," American Medical Association, June 2, 2026. https://www.ama-assn.org/medical-residents/transition-resident-attending/pondering-direct-primary-care-10-potential-benefits
4. Francesca Mathewes, "Direct primary care explained in 12 notes," Becker's Physician Leadership, October 28, 2025. https://www.beckersphysicianleadership.com/independent-practice/direct-primary-care-explained-in-12-notes/
5. Harvard Medical School, "How much are concierge medicine and direct primary care growing?" December 2025. https://hms.harvard.edu/news/how-much-are-concierge-medicine-direct-primary-care-growing
6. American Medical Association, Code of Medical Ethics Opinion 11.2.5, "Retainer Practices." https://code-medical-ethics.ama-assn.org/ethics-opinions/retainer-practices
7. "Growth In Number Of Practices And Clinicians Participating In Concierge And Direct Primary Care, 2018-23," Health Affairs, December 2025; summarized by Johns Hopkins University Hub, December 18, 2025. https://hub.jhu.edu/2025/12/18/concierge-medicine-rising-hopkins-research/
8. Francesca Mathewes, "Concierge medicine: Physicians weigh pros, cons," Becker's Physician Leadership, April 17, 2025. https://www.beckersphysicianleadership.com/news/concierge-medicine-physicians-weigh-pros-cons/
9. Eli Y. Adashi, Ryan P. Clodfelter and Paul George, "Direct Primary Care: One Step Forward, Two Steps Back," JAMA 2018;320(7):637-638. https://jamanetwork.com/journals/jama/article-abstract/2688238
10. Internal Revenue Service, "Treasury, IRS provide guidance on new tax benefits for health savings account participants under the One, Big, Beautiful Bill" (Notice 2026-5). https://www.irs.gov/newsroom/treasury-irs-provide-guidance-on-new-tax-benefits-for-health-savings-account-participants-under-the-one-big-beautiful-bill
11. Groom Law Group, "A Big, Beautiful Break for HSAs: IRS Guidance on the One Big Beautiful Bill Act's HSA Provisions." https://www.groom.com/resources/a-big-beautiful-break-for-hsas-irs-guidance-on-the-one-big-beautiful-bill-acts-hsa-provisions/
12. KFF, "Annual Family Premiums for Employer Coverage Rise 6% in 2025, Nearing $27,000," October 22, 2025. https://www.kff.org/health-costs/annual-family-premiums-for-employer-coverage-rise-6-in-2025-nearing-27000-with-workers-paying-6850-toward-premiums-out-of-their-paychecks/
13. Centers for Medicare & Medicaid Services, Medicare Benefit Policy Manual, Chapter 15, Section 40 (Opting Out of Medicare). https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf
14. Colorado Revised Statutes, Title 6, Article 23 (Direct Primary Care), Sections 6-23-102 and 6-23-104. https://law.justia.com/codes/colorado/2022/title-6/article-23/
15. U.S. Government Accountability Office, "Physician Services: Concierge Care Characteristics and Considerations for Medicare," GAO-05-929, August 12, 2005. https://www.gao.gov/assets/a247394.html
16. Centers for Medicare & Medicaid Services Innovation Center, "ACO Primary Care Flex Model." https://www.cms.gov/priorities/innovation/innovation-models/aco-primary-care-flex-model
17. AMN Healthcare, "2025 Survey of Physician Appointment Wait Times," May 2025 (family medicine metro data, p. 22). https://www.amnhealthcare.com/amn-insights/physician/whitepapers/2025-survey-of-physician-appointment-wait-times/
18. American Academy of Family Physicians, "2022 Direct Primary Care Data Brief." https://www.aafp.org/assets/image/upload/v1771216436/Migrated%20-%20PDFs%20(AEM)/Practice/direct-primary-care-2022-data-brief-pdf.pdf
19. Hannah T. Neprash et al., "Measuring Primary Care Exam Length Using Electronic Health Record Data," Medical Care 2021;59(1):62-66; summarized by Wolters Kluwer via EurekAlert, January 2021. https://www.eurekalert.org/news-releases/808249
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