Four Ways to Practice Medicine. Only One Aligns Payment with Care.

Fee-For-Service

Concierge

Direct Primary Care

Cash Per Visit

Most physicians work inside one of these structures. This guide helps you understand what each model actually is, what it actually feels like and who it actually serves.

Every physician in practice operates inside a payment model, whether they chose it intentionally or inherited it by default. Most medical training offers no formal language for this. Residents absorb the culture of their program. Attendings model the pace of their system. The payment structure becomes invisible, not because it is unimportant, but because it is everywhere.

This guide makes the invisible visible. It examines four distinct models of primary care delivery, not through statistics alone, but through the texture of what each model actually produces: for physicians, for patients, and for the practice of medicine itself.

01

Model One

Fee-for-Service

The dominant model. The default inheritance.

Fee-for-service is not a philosophy. It is a payment mechanism, one that has been in place long enough that most physicians cannot imagine medicine working any other way. At its most basic, the logic is straightforward: a physician provides a service, the service is coded, the code is submitted to an insurer, the insurer adjudicates the claim, and the physician receives a reimbursement.

On paper, this looks like a reasonable transaction. In practice, it has quietly shaped American medicine into something unrecognizable from what most physicians imagined when they entered training.

What the model rewards

Because revenue flows from visits, fee-for-service rewards volume. Not maliciously, not consciously, just structurally. The physician who sees 30 patients earns more than the physician who sees 20. The physician who documents a complex visit earns more than the physician who bills a simple one. Over time, the system teaches physicians to optimize for billable encounters, and the culture of a practice begins to reflect whatever the billing structure rewards.

Appointment slots compress to 10 or 15 minutes because longer slots mean fewer patients per day and lower revenue. Panel sizes grow to 2,000 or more because a larger panel means more potential visits. Preventive conversations get squeezed because comprehensive counseling often generates the same reimbursement as a brief check. And charting expands, not to communicate clinical thinking, but to justify the billing level.

The tragedy of fee-for-service is not that physicians stop caring. It is that the structure eventually makes caring at the level physicians want to practice nearly impossible, and the erosion is so gradual that many physicians do not notice until the damage is done.

What daily practice actually feels like

Ask a fee-for-service primary care physician to describe a normal Tuesday, and what emerges is a portrait of relentless compression. A full schedule by 7 a.m., a waiting room that stays full, a morning already behind schedule because the second patient arrived late and the fourth had an extra concern. By noon, documentation from the morning has not been finished. By 5 p.m., the physician is still charting. By 7 p.m., inbox messages need responses. By 9 p.m., prior authorizations remain.

None of this is exaggeration. It is the structural reality of a system that finances primary care on transaction volume. And because that reality is ubiquitous, it has come to feel like simply what medicine is, rather than what a particular payment arrangement has made medicine become.

I came home one night and couldn't remember a single patient from that day. Not one face. Not one story. I had seen 32 people. That was the moment I knew something had to change.

Primary Care Physician, My DPC Story Podcast

The moral injury beneath the burnout

Burnout in fee-for-service primary care is well documented. What is less often named is the precise nature of the injury underneath it. It is not primarily exhaustion, though exhaustion is present. It is the repeated experience of being unable to practice medicine at the level a physician knows is possible. The 12-minute appointment that ends before the patient has said everything important. The complex social situation that gets reduced to a prescription because there is no time for anything else. The patient who deserved 40 minutes who got 10.

That is not a staffing problem or a scheduling problem. It is a payment model problem. Fee-for-service makes depth unaffordable, because depth requires time, and time reduces visit volume, and reduced volume reduces revenue.

High administrative burdenVolume-dependent income

Wide insurance acceptance

Compressed visit time

Employment stability

Physician burnout risk

Who this model serves

Fee-for-service reaches the broadest range of insured patients and provides infrastructure for complex, multi-physician care systems. It works best in specialty and hospital settings where procedures and discrete interventions align with the per-service payment logic. In primary care, the fit has always been poor, because primary care's value is relational and longitudinal, not transactional.

Between models

Every model described here emerged as a response to the one before it. Concierge medicine emerged when physicians and patients who could afford to do so decided the fee-for-service pace was no longer acceptable. But the solution they found carried its own contradictions.

02

Model Two

Concierge Medicine

The premium escape hatch. Real benefits. Real tradeoffs.

Concierge medicine emerged in the late 1990s as a direct response to the suffocation of fee-for-service primary care. The insight was genuine: if patients were willing to pay a premium for access, and if that premium could fund a smaller panel and more time, then the relationship between physician and patient could be restored to something meaningful.

The insight was right. The execution has been more complicated.

How concierge actually works

In a traditional concierge practice, patients pay an annual or monthly retainer fee, typically ranging from $1,500 to $10,000 or more per year depending on the practice and its location. In exchange, they receive same-day or next-day access, extended appointment times, the physician's personal cell phone, and often a range of enhanced services including executive physicals, comprehensive wellness panels, or house calls.

Here is the critical structural detail that most people miss: in concierge medicine, insurance billing continues in parallel. The retainer is an add-on. Patients pay the retainer for enhanced access, and then insurance is still billed for individual visits and services. This means concierge medicine is simultaneously a membership model and a fee-for-service practice. The physician earns twice: once from the retainer and once from the insurer.

The promise of concierge medicine is genuine, and many concierge physicians provide exceptional care. But the model's structure reveals its underlying limitation: it is not a reimagining of how primary care is paid for. It is a premium tier added on top of the existing system.

What patients experience

Patients who can afford concierge medicine often describe it as transformative. The physician knows their name. Appointments run as long as needed. There is a direct line to the physician, not a nurse triage system. Preventive care is thorough rather than rushed. The experience of being a patient feels fundamentally different than anything fee-for-service primary care provides.

For these patients, concierge medicine delivers on its promise. The problem is that those patients represent a small fraction of the population, and the concierge model has no inherent mechanism to expand beyond the affluent.

The equity ceiling

Concierge practices typically serve panels of 300 to 600 patients who can each afford a retainer ranging from hundreds to thousands of dollars annually. This is not a criticism of the physicians who build them, but it is an honest observation about who the model reaches. When a physician moves from a 2,000-patient fee-for-service panel to a 400-patient concierge panel, the 1,600 patients who leave that practice go somewhere, usually into the already-overcrowded fee-for-service system.

The concierge model improves care for those it serves. But it does not address, and in some ways compounds, the access problem for everyone else.

My concierge patients got great care. I loved practicing that way. But I knew every day that what I was doing wasn't for everyone, and that bothered me more than I admitted at the time.

Physician who later transitioned to DPC, My DPC Story Podcast

The administrative paradox

Because concierge medicine retains insurance billing for individual services, it also retains much of the administrative overhead that comes with it. The practice still needs coders, billers, and claim managers. Prior authorizations still exist. Reimbursement disputes with insurers still happen. The retainer provides supplemental revenue and justifies a smaller panel, but it does not simplify the practice's financial operations the way a fully insurance-free model would.

Moderate administrative burden

Extended appointment time

High patient cost

Small panel size

Limited equity reach

Dual revenue stream

Who this model serves

Concierge medicine serves patients who value access and relationship above all else and have the financial resources to pay for it directly. It works well for executives, professionals, and high-net-worth individuals in urban markets who are accustomed to premium service across other areas of their lives. It is a poor fit for physicians who entered medicine to practice broadly across income levels, or who want to build something simpler and more sustainable.

Between models

What if the retainer model worked, but the insurance billing was removed entirely? What if the monthly fee was not a premium add-on, but the sole mechanism for primary care revenue? That question is what Direct Primary Care set out to answer.

03

Model Three

Direct Primary Care

Not a premium tier. A structural reinvention.

Direct Primary Care takes the most valuable insight of concierge medicine, that a membership structure allows smaller panels and deeper relationships, and strips away the element that limits its reach: the continued dependence on insurance billing.

In DPC, patients pay a flat monthly membership fee, typically between $50 and $150 depending on age, region, and practice. That fee is the only payment mechanism for primary care. There are no per-visit charges. No insurance claims for routine care. No coding complexity. No prior authorization for primary care services. The physician earns from members. The patient gets a physician.

The structural difference that changes everything

The most important distinction between DPC and concierge medicine is not the price, though DPC is typically far more accessible. It is the relationship between revenue and time. In concierge medicine, insurance billing continues, which means visit volume still influences income to some degree. In DPC, revenue is entirely decoupled from visit count. Whether a member comes in twice in a month or not at all, the physician earns the same.

That decoupling is the mechanism behind everything that makes DPC practitioners sound like they are practicing a different kind of medicine, because structurally, they are. The incentive no longer points toward volume. It points toward health. Keeping members healthy enough not to need frequent visits is now financially rational, where in fee-for-service it would reduce revenue.

DPC does not make physicians better people. It removes the structural forces that prevent good physicians from practicing at the level they are actually capable of. The time was always available. The model was consuming it.

What a DPC day actually feels like

A DPC physician with 550 members might see 8 to 12 patients on a typical day. Appointments run 30 to 60 minutes as standard. There is a lunch break. There is time to think between patients. Charting happens during the visit or immediately after, not at 9 p.m. A patient calls with a question, and the physician answers or calls back, because fielding the call prevents an unnecessary appointment and keeps the member healthy. The inbox is manageable. The day ends.

This description is not fantasy. It is documented, in hundreds of episodes on the My DPC Story podcast, by physicians who were practicing fee-for-service primary care one year and DPC the next. The recurring observation across all of them is not that they became different physicians. It is that they became able to practice medicine the way they had always wanted to.

A patient said to me last year, "You're the first doctor who has ever asked me how I'm sleeping." She'd had a primary care doctor for 20 years. I'd been her doctor for six months. That's the DPC difference, and it's purely structural.

DPC Physician, My DPC Story Podcast

The accessibility argument

At $75 to $100 per month for an individual, DPC is not universally affordable, but it is meaningfully more accessible than concierge medicine. And the model's flexibility allows equity-minded physicians to design around the affordability barrier in ways concierge never could: tiered pricing, family caps, employer-sponsored contracts that bring DPC to working-class employees as a benefit, community scholarships funded by full-paying members.

Since January 2026, the accessibility argument has improved further. Under H.R. 1, signed into law on July 4, 2025, DPC membership fees can now be paid using HSA funds. Patients on high-deductible plans can route their DPC membership through a pre-tax account, reducing the effective cost and removing one of the most persistent objections from cost-sensitive prospective members.

The ownership dimension

DPC is also, for many physicians, the only realistic path to practice ownership without the capital requirements of traditional private practice. With lower overhead, no billing infrastructure, and simpler staffing, a DPC physician can launch for under $50,000 in many markets. What a physician builds is theirs. The culture is theirs. The panel is theirs. The schedule is theirs. For physicians who entered medicine wanting to build something, not just work somewhere, DPC provides a structural path that fee-for-service employment rarely does.

Minimal administrative burden

Stable recurring revenue

Small panel, deep relationships

Schedule autonomy

Panel growth takes 12–24 months

HSA-eligible since Jan 2026

Who this model serves

DPC serves patients who value relationship, access, and transparency over broad specialist network coverage. It works especially well for families, young professionals with high-deductible plans, small business employees covered by employer contracts, and patients frustrated by the impersonality of high-volume primary care. It serves physicians who value depth over volume, autonomy over employment stability, and building something lasting over inheriting an existing system.

Between models

There is a fourth model that receives far less attention than the others, partly because it operates with the least infrastructure and the most simplicity. Cash-per-visit medicine is neither membership nor insurance. It is medicine paid for like almost everything else: directly, at the time of service, for exactly what was provided.

04

Model Four

Cash Per Visit

The simplest model. And the most misunderstood.

Cash-per-visit medicine is exactly what it sounds like. A patient comes to see a physician. The physician charges a flat fee for the visit, typically $75 to $200 depending on complexity. The patient pays at the time of service. There is no insurance billing, no coding, no prior authorization, and no monthly membership. There is a physician, a patient, and a direct transaction.

At its best, cash-per-visit medicine represents the most radical simplification of the payment relationship in primary care. No intermediaries. No recurring commitment. No administrative layer between the clinical encounter and the revenue it generates.

The appeal, and who it attracts

Cash-per-visit practices attract two distinct physician profiles. The first is the physician who wants maximum simplicity and minimum overhead, often a solo practitioner or a physician working part-time, who wants to provide care without the complexity of either insurance billing or membership management. The second is the physician who operates a cash practice as a complement to other work, urgent care shifts, locum work, or telehealth, as a way to see patients on their own terms without committing to a full panel.

For patients, cash-per-visit makes sense in specific circumstances. The patient who rarely needs primary care and does not want a monthly commitment. The uninsured patient who wants to pay a predictable amount without navigating complex billing. The traveler or temporary resident who needs episodic care. The patient who simply wants to pay for exactly what they use and nothing more.

Cash-per-visit is genuinely simpler than any other model. But simplicity has a shadow side: without a continuing relationship, the longitudinal dimension of primary care, the part that catches the pattern across years, is often the first casualty.

What the model cannot provide

The limitation of cash-per-visit medicine is structural, not moral. Because there is no ongoing relationship by design, the model naturally produces episodic rather than longitudinal care. A physician who sees a patient once for an acute concern and then not again for 18 months cannot provide the continuity that primary care's most powerful contributions require: the pattern recognition across time, the accumulating knowledge of a patient's family history and risk factors, the trust that allows a patient to mention the thing they have been embarrassed to bring up.

Primary care's value is not primarily in the single visit. It is in the accumulation of visits, in the physician who knows what last year's labs looked like, who remembers the stress that was happening when the blood pressure first went up, who can detect the slow drift in a patient's presentation that signals something changing. Cash-per-visit medicine, by its nature, makes that accumulation structurally difficult.

I ran a cash clinic for two years. I loved the simplicity. What I didn't expect was how much I missed knowing people. Every visit was a first visit. That gets hollow faster than you'd think.

Physician who transitioned from cash to DPC, My DPC Story Podcast

Where cash-per-visit fits in the ecosystem

Cash-per-visit is not a failed model. It is a model with a specific and limited application. It works well as a complementary service inside a DPC or concierge practice, offering an on-ramp for prospective members who are not yet ready to commit. It works well in urgent care settings where episodic care is the point. It works well for physicians who want maximum flexibility without panel responsibility.

What it does not work well for is the core mission of primary care as it has been defined and practiced at its best: a continuous, comprehensive, coordinating relationship with a patient across the full arc of their health. For that mission, the model requires recurring revenue, recurring access, and recurring relationship. Cash per visit provides the transaction but not the thread.

Minimal overheadMaximum simplicity

No continuity by designIncome not predictable

Good for episodic needsFlexible for part-time practice

Who this model serves

Cash-per-visit works best for patients with low primary care utilization who want transparent, commitment-free pricing, and for physicians who want part-time or supplemental practice without panel management responsibilities. It is a poor fit for physicians who want to practice the full depth of primary care, or for patients with chronic conditions who need the kind of longitudinal knowing that only continuity produces.

Bringing it together

What each model actually optimizes for

Every model has real strengths and real limitations. The question that matters is not which model is objectively best, but which model aligns with what you believe primary care is actually for.

Fee-for-Service

Optimizes for volume and reach. Can serve the broadest insured population. Produces maximum access in raw numbers while systematically undermining the depth that makes that access meaningful.

Concierge

Optimizes for depth within an affluent subset. Restores the relationship and time that fee-for-service erodes, but charges a premium that limits it to patients who can afford the upgrade.

Direct Primary Care

Optimizes for the physician-patient relationship at a price point that reaches far beyond concierge. Removes the billing infrastructure that drives volume pressure while retaining the continuity that cash medicine loses.

Cash Per Visit

Optimizes for simplicity and transparency. Excellent for episodic and supplemental care. Structurally unsuited to the longitudinal, knowing-you-across-time nature of comprehensive primary care.

If you entered medicine to know your patients across years, to catch the thing that only a long relationship reveals, to practice preventive care that actually reaches the root of why someone is sick, then the model that removes the structural barriers to that practice is the one worth your serious attention. DPC does not solve every problem in medicine. But it solves the structural ones that prevent primary care from functioning at the level its practitioners were trained to provide.

You Don't Have to Figure This Out Alone

Whether you're a pre-med building your first mental map of how medicine works, a Resident deciding what kind of practice to build, or an attending physician wondering if the model you are in is the right one, the community exists to help you think it through.

Real physicians. Real stories. Real numbers.