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More primary care practices ditch insurance for direct care
A study reveals an increasing number of practices and clinicians transitioning to concierge and direct primary care models in a move that cuts medical billing's administrative burden.
More primary care practices are fed up with traditional medical billing through patients' insurance, prompting them to set up alternative billing options, including concierge and direct primary care, according to a new study.
The study published in the December 2025 edition of Health Affairs found an 83% increase in the total number of concierge and direct primary care practices from 2018 through 2023. By the end of the period, there were over 3,000 of these types of practices, compared to approximately 1,658 two years prior.
The number of clinicians in concierge and direct primary care also rose significantly, from 3,935 in 2018 to 7,021 in 2023, representing a 78% increase. This increase was largely due to growth in the advanced practice clinician workforce (from 32.7% in 2018 to 40.3% in 2023) versus physicians (from 67.3% to 59.7%).
Additionally, the study found that there were fewer independently owned concierge and direct primary care practices during the period. The share of independent practices declined from 84% to about 60%, while practices affiliated with corporate-owned, including hospitals and health systems, increased from about 9% to 34%.
Still, concierge and direct primary care practices remained small, with the typical practice employing fewer than five clinicians.
Concierge and direct primary care models may not be the norm, but they are offering an attractive alternative to traditional medical billing and revenue cycle management, which clinicians have long complained about. Low reimbursement rates, as of late, have also put pressure on practices to reconsider their revenue models.
However, study authors worry that ditching insurance or practicing a hybrid model may impact access to care.
"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," said Dan Polsky, co-author of the study and a Bloomberg Distinguished Professor with joint appointments at the Johns Hopkins Carey Business School and the Johns Hopkins Bloomberg School of Public Health. “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 difference between concierge and direct primary care
Concierge and direct primary care models move away from the traditional medical billing approach, which relies on patients' insurance plans to reimburse providers for the majority of services. In a more extreme alternative, direct primary care works completely outside of the insurance approach.
In direct primary care, patients pay providers a membership fee, typically paid monthly, to cover most in-office primary care, such as visits, basic labs and procedures. The model aims to deliver a predictable, lower-cost option for patients compared to traditional insurance plans. Patients also tend to get greater access to their providers for more comprehensive routine and preventive care.
Concierge medicine differs because providers in this model still bill patients' insurance for visits and procedures. So, patients are still responsible for co-pays and other cost-sharing, in addition to a membership fee. These fees are also generally significantly higher compared to direct primary care, often costing thousands of dollars a year. Still, patients tend to access care more easily, and the care covered by concierge medicine tends to be more extensive, including wellness plans, executive physicals and specialized screenings.
Surveys have shown that providers often adopt one of these models for greater autonomy, a better work-life balance, and fewer administrative hurdles. These models can also offer revenue stability, whereas insurance can update rates and patients may switch plans.
Sun rising on the horizon for concierge, direct primary care
While direct primary care shifts practices out of the traditional, insurance-based revenue model, the Health Affairs study found that many practices in these alternative practice models are still billing Medicare.
Researchers linked their data to publicly available Medicare files to find that about 60% of clinicians in their sample were concierge practices or in some hybrid model based on their presence in Medicare data. The other 40% was not included in Medicare data, indicating that these clinicians are in direct primary care, the study stated.
These hybrid models may maintain the traditional revenue approach while offering a separate, premium, membership-based service to some of its patients. For Medicare patients, in particular, it may separate the services covered by the program from the amenities offered by the concierge aspect of the practice.
Practices may be tapping into a growing Medicare population, particularly those seeking more comprehensive services than what the federal program covers. Health systems have also increasingly advertised hybrid models alongside their primary care options, the study stated.
The future appears promising for concierge and direct primary care. More practices and clinicians are moving to the models and finding ways to accommodate some populations. President Donald Trump's federal spending law, known as the One Big Beautiful Bill Act, also bolsters their popularity as changes to health savings accounts allow for spending on membership fees to concierge and direct primary care practices.
Still, the rise in these models points to the challenges associated with operating a primary care practice, including medical billing and revenue cycle management.
"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," stated Polsky. "The increasing interest clinicians are showing in fee-based practices may be telling of certain pain points clinicians face in traditional primary care settings."
Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.
