Some of his patients don’t have insurance; others have high-deductible plans. Some have Medicare or employer-based insurance but want a simpler system or faster access. His patients, Gold said in an interview, “are tired of being treated as a number in a system that focuses on insurance rather than care.”
Gold is one of a growing number of physicians — with a growing number of patients — shifting to concierge care, where patients pay a fee for quicker physician access, or direct care, where patients pay out of pocket.
The growth of these new models is an indictment of the problems with access and affordability in the current health care system. It makes sense that patients who face monthslong waits to see a new primary care doctor or to get a specialist appointment will seek other options, even if that means spending more money. Occasionally, paying out of pocket can be cheaper than using insurance. But these new models can’t be the only solution for fixing the broken health care system. While these models might work for those who can afford them, they also exacerbate access challenges for people who can’t pay out of pocket.
In some corners, these inequities are leading to stronger advocacy for single-payer health care, in which government acts as the insurer. But for those who continue to believe in a market-based system, the challenge will be finding ways to fix the current system so people are no longer tempted to abandon it.
“These models have come up because they address massive market failures in an ever-more-expensive health care landscape,” said Asaf Bitton, executive director of Ariadne Labs, a health systems innovation center. “People see themselves paying more for health care that they can’t access. … And there’s only so much people, especially people with means, want to be put in a queue around.”
According to a study in Health Affairs, the number of clinicians engaging in concierge or direct care medicine grew from 3,935 clinicians at 1,658 practices nationwide in 2018 to 7,021 clinicians at 3,036 practices in 2023, a growth of around 80 percent. (The data don’t distinguish between concierge and direct care, and the authors said there are probably more practices that weren’t included in the data.) Study coauthor Zirui Song gave me a breakdown by state showing that Massachusetts had 75 such clinicians at 28 practices in 2018, which grew to 156 clinicians at 42 sites by 2023.
Since then, the Massachusetts Health Policy Commission has found continued growth in membership-based models of care like Amazon’s OneMedical or hospital-run concierge practices. These tend to have smaller patient panels and quicker access to physicians than traditional doctors’ offices.
For patients who need specialty care, there are technologies like UBERDOC, a website that lets patients book appointments quickly online for an out-of-pocket fee. UBERDOC founder Paula Muto is a North Andover surgeon who became frustrated with how hard it could be to access care quickly when it required insurance approval. Muto said her site is about “restoring patient autonomy.”
The site has about 5,000 doctors registered nationwide. A recent search for a dermatologist near Boston turned up three doctors within 10 miles, each with one appointment available in the next week, for a total cost of $250. A search for a Boston cardiologist found one at St. Elizabeth’s Medical Center offering a $200 video visit the next day.
To be clear, there are downsides to these systems. Ideally, insurance companies require referrals and prior authorizations to ensure a person doesn’t get — and pay for — unnecessary care. Someone booking a self-pay appointment loses that check.
Importantly, these programs aren’t universally affordable. Massachusetts General Hospital’s concierge practice, for example, charges a $10,000 annual membership fee, in addition to any cost-sharing required by insurance for services.
And when physicians leave general practice to take fewer patients, that exacerbates shortages in areas like primary care and makes it harder for non-private-pay patients to find doctors.
The growth in private-pay care is sparking a backlash from those who see it as increasing inequities. Brian O’Malley, a retired Provincetown physician and longtime advocate for single-payer health care, said the private-pay market creates “two-class care.” O’Malley said he’s seeing growing interest in having one government-run insurer as a more equitable way to avoid the burdens of the current insurance system. In 2024, a single-payer advocacy group asked voters in 11 Massachusetts districts a nonbinding ballot question supporting the creation of universal public insurance — and every district voted in favor.
Of course, single-payer systems also have downsides: A government isn’t usually more efficient than private industry, and a set reimbursement rate could potentially lead to longer wait times for care and less innovation, lowering care quality.
The best solution is not eliminating or escaping the system we have now but fixing it. We should be thinking about how to improve access to primary care and timely specialty care. We should discuss how to make the insurance system simpler and shore up the health care workforce. Simultaneously, we need to ensure people can afford both insurance and care. If our health care system isn’t affordable or accessible, patients will continue seeking alternatives.
Shira Schoenberg can be reached at shira.schoenberg@globe.com. Follow her @shiraschoenberg.
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