Hosted by Michael Tetreault | Editor-in-Chief, Concierge Medicine Today
Episode Overview
In one of the most comprehensive episodes in DocPreneur Leadership Podcast history, host Michael Tetreault takes an honest, evidence-based, and encouraging look at the cash-pay and subscription-based primary care landscape — who it serves, how it works, where it's heading, and what every physician and advanced practice clinician needs to understand before making a career-defining decision.
This episode doesn't take sides. It takes a clear-eyed look at the full picture — including the parts that don't always make it into the conference keynote.
What's Covered in This Episode
The Foundation
Not all subscription-based primary care models are the same. Two models operating in this space share surface-level similarities but are structurally distinct businesses with different economic logic, different patient populations, and different long-term trajectories. Understanding which one you're considering — and why — changes everything about how you plan.
A Lesson From Healthcare History
Before committing to any practice model, it helps to understand what happened to the movements that came before it. This episode traces three instructive parallels: the micropractice and ideal medical practice movement of the early 2000s; the decades-long fight for healthcare price transparency and what happened when physicians finally got it; and the rise and reality check of retail health — what scaled, what didn't, and why. The common thread in every model that has achieved durable scale in American healthcare is the same: structural fit with the economic environment, not ideological purity.
Two Pathways, One Brand Name
The episode walks through both economic models in the cash-pay primary care space — the purist, cash-only, no-insurance model and the employer-integrated model — explaining how each works, who each serves, and what the financial picture actually looks like for physicians considering either path. The revenue math is done out loud. The sustainability data from peer-reviewed research is cited. The patient demographic fit for each model is examined honestly and specifically.
Who Each Model Serves — and Where Other Models Fit Better
A detailed breakdown of the patient populations each model genuinely serves well — and an honest, evidence-based look at the patient populations where other models may be a better structural fit. Including Medicare-eligible patients, patients with complex chronic disease, lower-income households, and employees of small and mid-sized businesses.
The Overlooked Opportunity — NPs, PAs, and Advanced Practice Clinicians
One of the most significant and underexplored opportunities in subscription-based healthcare delivery today is the direct-care model as a pathway for nurse practitioners, physician assistants, and other advanced practice clinicians. The evidence on NP and PA-led primary care outcomes is strong and peer-reviewed. The physician shortage projections make the need urgent. And the organizational infrastructure for advanced practice clinician-led direct-care practices is largely unbuilt — which means the opportunity belongs to whoever moves first.
The Organizational Landscape
An honest look at what the multiplicity of organizations, coalitions, and alliances in the cash-pay primary care space tells us — and what research on professional association dynamics says about the long-term implications of organizational fragmentation for legislative effectiveness and individual practice planning.
One Brand, Two Directions
Drawing on four documented historical parallels from the history of American medicine — the AMA and managed care, osteopathic medicine's identity divide, family medicine's emergence as a separate specialty, and the micropractice movement — the episode makes the case that two communities with genuinely different economic interests and regulatory priorities currently sharing a brand name may, consistent with historical precedent, find their own distinct professional homes over time. This is presented as pattern recognition grounded in verified historical evidence — and as practical planning context for physicians building practices today.
The Tax and Structuring Update
A clear, practical summary of the 2025 "One Big Beautiful Bill" Act changes — effective January 2026 — and what they mean for HSA eligibility of cash-pay membership fees. What qualifies, what doesn't, and why legal counsel is essential before making any representations to patients about tax-advantaged payment options.
Eight Questions Before You Commit
A practical pre-decision checklist — eight specific questions every physician or advanced practice clinician should be able to answer clearly before committing to any cash-pay practice pathway.
Key Takeaways
- Cash-pay primary care and concierge medicine are not the same model, do not serve the same patient populations, and should not be evaluated as interchangeable alternatives.
- The purist cash-pay model has grown from approximately 100 practices in 2009 to over 2,100 by 2023 — real and meaningful growth. The financial sustainability data, however, reflects consistent challenges that peer-reviewed research has documented specifically in lower-income markets and solo practice settings.
- The employer-integrated pathway has stronger structural sustainability — multiple revenue streams, embedded benefit relationships, and documented employer cost reductions of 12 to 20 percent over three to five years.
- A December 2025 Johns Hopkins study found concierge and cash-pay primary care practices combined grew 83.1 percent between 2018 and 2023. The employer-integrated model is the primary driver of that growth trajectory.
- Concierge medicine — particularly the PCM model — is not retreating. The global concierge medicine market is projected to surpass $34 billion by 2032 and is growing at a compound annual rate that outpaces most healthcare market segments.
- The National Academy of Medicine's 2021 Future of Nursing report, AAMC physician shortage projections, and peer-reviewed NP/PA outcomes research collectively point to advanced practice clinician-led direct-care models as one of the most significant underexplored opportunities in subscription-based healthcare delivery.
- Pattern recognition from healthcare history — price transparency, retail health, the micropractice movement — consistently shows that the distance between a compelling healthcare idea and durable scaled impact is longer and more complicated than early advocacy suggests.
- Models that have achieved durable scale in American primary care share one characteristic: structural fit with the economic environment, not independence from it.
Sources and Citations
All claims in this episode are supported by published, verifiable sources. Full citations below.
Micropractice and Practice Model History
- Moore, G. (2002). "Accountability and Improvement in Physician Practice." Family Medicine.
- Moore, G. & Showstack, J. (2003). "Primary Care Medicine in Crisis." Health Affairs. healthaffairs.org
- AAFP TransforMED Initiative. (2006). aafp.org
- Nutting, P.A. et al. (2010). "Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home." Annals of Family Medicine.
- Rittenhouse, D.R. et al. (2009). "Primary Care and Accountable Care." New England Journal of Medicine.
- Rittenhouse, D.R. & Shortell, S.M. (2009). "The Patient-Centered Medical Home." JAMA.
Price Transparency Research
- Pathak, Y. & Muhlestein, D. (2024). "Public Awareness and Use of Price Transparency: Report From a National Survey." West Health Institute / Gallup. pmc.ncbi.nlm.nih.gov
- Parente, S.T. (2023). "Estimating the Impact of New Health Price Transparency Policies." Inquiry.pmc.ncbi.nlm.nih.gov
- ScienceDirect. (2025). "Outcomes of Price Transparency Policies for Healthcare Services in the United States: A Systematic Review." sciencedirect.com
Retail Health
- Fein, A.J. (2017). "Retail Clinic Check Up: CVS Retrenches, Walgreens Outsources, Kroger Expands." Drug Channels. drugchannels.net
- CNBC. (2024). "Why Walmart, Walgreens, CVS Retail Health Clinic Experiment Is Struggling." cnbc.com
- Healthcare Finance News. (2023). "Retail Clinics Seeing Utilization Soar, Popularity Grow." healthcarefinancenews.com
- MedCity News. (2023). "Retail Clinics Are Gaining Momentum." medcitynews.com
Cash-Pay and Subscription Primary Care Market Data
- MedCity News. (March 2026). "DPC Is Scaling — The Financing Architecture Isn't Ready." medcitynews.com
- Johns Hopkins. (December 2025). Study on concierge and cash-pay practice growth 2018–2023. As cited in MedCity News, March 2026.
- Liaw, W. et al. (2024). "Direct Primary Care: Financial Analysis and Potential to Reshape the U.S. Healthcare Landscape." Journal of General Internal Medicine. springer.com
- Lujan, D.Y. (2025). "Why Direct Primary Care Models Fail." KevinMD. kevinmd.com
- Doan, L. et al. (2019). "Physician Perspectives on Direct Primary Care." Family Medicine.
- Eskew, P.M. & Klink, K. (2015). "Direct Primary Care: Practice Distribution and Cost Across the Nation." Health Affairs. healthaffairs.org
- Tseng, P. et al. (2018). "Administrative Costs Associated With Physician Billing and Insurance-Related Activities." JAMA Internal Medicine.
- Medscape Physician Compensation Report. (2023). medscape.com
Employer-Integrated Model
- Spann, S.J. et al. (2020). "Employer-Sponsored Direct Primary Care." Journal of Occupational and Environmental Medicine.
- National Alliance of Healthcare Purchaser Coalitions. (2021). purchaseralliance.org
- Kaiser Family Foundation. (2023). Employer Health Benefits Annual Survey. kff.org
- National Business Group on Health. (2022). businessgrouphealth.org
- Employers Health Coalition. (2022). employershealthcoalition.org
Patient Demographics and Population Health
- Anderson, G.F. (2010). "Chronic Conditions: Making the Case for Ongoing Care." Johns Hopkins Bloomberg School of Public Health.
- Tikkanen, R. & Abrams, M.K. (2020). "U.S. Health Care from a Global Perspective." Commonwealth Fund.commonwealthfund.org
- Collins, S.R. et al. (2022). "Paying for It: How Health Insurance and Healthcare Costs Are Shaping the Lives of American Adults." Commonwealth Fund. commonwealthfund.org
- Bureau of Labor Statistics. (2023). "Contingent and Alternative Employment Arrangements." bls.gov
- Petterson, S. et al. (2012). "Unequal Distribution of the U.S. Primary Care Workforce." Annals of Family Medicine.
Advanced Practice Clinicians and Nursing
- Laurant, M. et al. (2019). "Revision of Professional Roles and Quality Improvement in Primary Care." New England Journal of Medicine.
- Naylor, M.D. & Kurtzman, E.T. (2010). "The Role of Nurse Practitioners in Reinventing Primary Care." Health Affairs. healthaffairs.org
- National Academy of Medicine. (2021). "The Future of Nursing 2020–2030." nationalacademies.org
- AAMC. (2021). "The Complexities of Physician Supply and Demand: Projections from 2019–2034." aamc.org
Legal, Tax, and Compliance
- Eischen, J. (2025). Legal Commentary on Cash Practice Structuring. eischenlawoffice.com
- DLA Piper. (2025). "Paying for Direct Primary Care Arrangements With HSAs." dlapiper.com
- IRS Notice 26-05. irs.gov
- CMS. "Opt-Out Affidavits and Private Contracts." cms.gov
Organizational and Professional Identity Research
- Hoff, T.J. (2010). Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-First Century. Rutgers University Press.
- Scott, W.R. (2008). Institutions and Organizations: Ideas and Interests. SAGE Publications.
- Freidson, E. (2001). Professionalism: The Third Logic. University of Chicago Press.
- Wolinsky, H. & Brune, T. (1994). The Serpent on the Staff: The Unhealthy Politics of the American Medical Association. Putnam.
- Gevitz, N. (2004). The DOs: Osteopathic Medicine in America. Johns Hopkins University Press.
- Stephens, G.G. (1989). "Family Medicine as Counterculture." Journal of Family Practice.
- Colwill, J.M. (1992). "Where Have All the Primary Care Applicants Gone?" New England Journal of Medicine.
- Meltzer, D.O. & Chung, J.W. (2014). "The Population-Based Physician Workforce." Health Affairs.healthaffairs.org
- Bodenheimer, T. & Pham, H.H. (2010). "Primary Care: Current Problems and Proposed Solutions." Health Affairs. healthaffairs.org
- Grumbach, K. & Grundy, P. (2010). "Outcomes of Implementing Patient Centered Medical Home Interventions." JAMA.
Concierge Medicine Market Data
- Grand View Research. (2022). Concierge Medicine Market Size & Growth Report. grandviewresearch.com
- Precedence Research. (2023). U.S. Concierge Medicine Market Size and Forecast. globenewswire.com
- MDVIP. (2020). Personalized Primary Care Reduces ER Visits, Hospitalizations, and Outpatient Expenditures.mdvip.com
- AAPP / Software Advice. (2023). "Concierge Medicine Salary and Definition." softwareadvice.com
Disclaimer
The DocPreneur Leadership Podcast is produced by Concierge Medicine Today, LLC, an independent healthcare leadership publication. This episode and its accompanying summary are intended for educational and informational purposes only.
Nothing in this episode or summary constitutes medical, legal, financial, or accounting advice. The information presented reflects publicly available research, published data, and editorial observation, and is not intended to replace the guidance of qualified medical, legal, financial, or business professionals.
All factual claims are supported by named, verifiable third-party sources, which are cited in full above. Concierge Medicine Today makes no guarantee regarding the completeness or currency of external sources cited and encourages listeners to verify information independently.
References to specific organizations, publications, legal decisions, or market data are provided for educational context only. Mention of any organization, publication, or individual does not constitute endorsement, and no commercial relationship exists between Concierge Medicine Today and any source cited in this episode unless otherwise disclosed.
Physicians, nurse practitioners, physician assistants, and other clinicians considering any practice model change are strongly encouraged to seek qualified legal counsel with specific experience in healthcare compliance, tax structuring, and the applicable regulatory environment in their state before making any practice or business decisions.
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