“All doctors are going concierge, what gives?”

Behind the scenes of insurance denials, rising overhead, and why private practice is fighting to survive.

You went for follow-up with your gynecologist and were told that now there’s an annual fee of $350 just to be a part of this practice. You’ll still pay your copay, you’ll still pay for labs, you’ll still have insurance denials to deal with, but you’ll also be responsible for this fee.

This is happening in primary care, pediatrics, cardiology, and in many other specialties. So why is this happening and is it good or bad for you?

Welcome to the Physician-Led Health Coaching weekly newsletter. I’m Dr. Ashori, a board-certified physician & health coach. I help people fix brain fog, fatigue, and stubborn weight before they turn into real disease.

“The Doctor is Getting Rich”

Most of these practices are called Concierge Clinics. They aren’t on Rodeo and they don’t have an all-glass facade. They are concierge because they operate as a hybrid model - a monthly or annual cash free along with the insurance reimbursement.

The practice started out with a mix of commercial insurance, Medicaid, and Medicare. But the doctor was taking home only $150K a year, half of what she could get if she worked for a large mega-corp. And she loves her practice but can’t cover her overhead.

She can’t force the third party payers to reimburse her more so she’ll either have to see more patients, offer subpar care, or turn to her patients for the difference.

If she had 2,500 patients in her practice and went concierge, she’ll likely have 1,500 patients stay and accept the concierge fee: $525,000/yr.

Now she can spend more time per patient, spend more time on claim denials and prior authorizations. She can hire an extra staff member, upgrade to better software, and improve customer service.

In the end, she’ll keep an extra $100K, at most, from this new concierge fee. It will be enough to keep her from joining the nearby mega hospital system.

Hybrid Clinics Are Problematic

I personally find hybrid clinics problematic. As a physician you have to cater to the insurance company because they are the ones paying you - not the patient. The patient pays you a small amount of sometimes no copay at all. But the majority of your income is paid by the insurance company, as long as you do things exactly the way they say.

Then you have this cash-based part of the practice where the patient is paying you directly. Let’s face it, it’s really a membership fee. A membership to keep your current doctor. It’s not really pleasant for anyone to be told,

“Hey, I’ve been your doctor for a few years, and we’ve built rapport, if you want to keep me and avoid the headaches of starting all over again, you have to pay me extra.”

Even though they are a problem, I haven’t found a better solution for someone who is already in a practice.

My practice is cash-only. I can’t fathom having an insurance company tell me what I can and can’t do for a patient. But that’s because I built it from the ground up as a cash-based, out-of-network practice.

“I Can’t Afford It”

This is a very valid statement for someone who simply can’t come up with an extra $350. But in our modern society “afford” is used in more creative ways.

If you are paying $1,000 a month for health insurance it’s not really feasible to say you can’t afford $30 a month for better medical care (assuming the extra time and attention would translate into better care.)

The science says that prevention and early screening improves health outcomes. If this is correct then spending extra money now would help you stay healthier longer, prevent suffering, and add more productive years to your life.

Health insurance will only go up in price. Yes, eventually a catastrophic plan will be added once enough people opt out of insurance and go to the ER for their care, but for now everyone is held hostage to whatever price hikes come our way.

There are DPCs (direct primary care doctors) and DSC (direct specialty care) and there are health-sharing companies like Zion and CrowdHealth. In fact, this is the combo my wife and I are using right now and we’re both doctors.

There are '“experts” who say that DPC is not a viable model and crowd-sourced or health-sharing plans are a scam. But my wife and I, both physicians, disagree. Just like any service or subscription, you have to go in informed. It’s not what I’m recommending, it’s just what we’re using at this time.

More Diseases, More Treatments, More Complexity

If you’ve been going to your doctor for the past 10 years here’s what’s change in the last decade:

• there are more diseases in the ICD10 code system

• more medications in our repertoire

• you probably have more health conditions

• more vaccine options to sort through

• more imaging technology to choose from

• more specialties or topic experts to refer to

• higher rate of malpractice cases to deal with

• a more complex credentialing system for doctors

With all of this added on, not to mention inflation, most private practice doctors can’t stay in business. They’ll need to hire more staff and subscribe to more software to keep their practice running.

So Why Bother With Private Practice

This is a valid point. Most adults are part of large hospital-based medical groups. They get everything in one place. Easy referrals and all of their data is readily shared between the different tentacles of the medical group.

And that’s exactly the problem. That large hospital-based medical group is also quite busy analyzing your health data to see how they can squeeze a few more health dollars from you and your insurance company.

They have your best interest in mind, no doubt, but it’s just under their own best interest, which is profits.

We could say the same for the private practice doctor. I certainly wouldn’t stay in practice if I didn’t get paid. But I could get paid far more working for that same large medical group. So, obviously profits aren’t my main motivation.

Maybe this is exactly why many private practice doctors may be a better fit for most patients; because their first priority is practicing medicine the way they see fit, followed by making a decent living, followed by their patient’s best interest. Don’t be offended by this, I’m a patient myself and I would never go to a medical practice that has no sustainable business model and only cares about my health. That’s because they wouldn’t be around for too long.

Frustrated by one-size-fits-all advice? I take on a limited number of 1-on-1 coaching clients to dive deep into your unique health history, identify your physiological triggers, and design a sustainable plan to help you feel your best.

So What Can You Do?

1. The good news is that there are lots of practices that haven’t and likely won’t go concierge. But you’ll wait a long time to see your doctor, wait a long time for referrals, and get frustrated waiting for your refills. Your clinician, though, will genuinely care about you, same with their staff.

2. You can pay the concierge fee knowing that it will make the practice run smoother and help improve your health along with it. Expect to pay $200 - $50,000 per year.

3. Go to a DPC/DSC practice. You’ll pay a small fee every month ($75-150) and never have to worry about the conflict of interest with the insurance company. But it’s advisable to keep your health insurance to pay for the really big things like emergencies.

4. Invest in your health literacy because no matter what system you use, you never want to be at the mercy of the healthcare system. You want the advice and guidance from your clinician that you can vet yourself.

5. Sign up for a health sharing ministry like Zion or CrowdHealth. But you’ll want to read the fine print. Many things are not covered but big unexpected bills usually are.

Disclaimer:

Dr. Mohammad Ashori is a U.S.-trained family medicine physician. The content shared here is for education and general guidance. It is not personal medical advice, diagnosis, or treatment, and it does not create a doctor-patient relationship. Humans are complicated and your personal details matter. Your healthcare team is your best resource before making medical decisions, changing medications, or managing symptoms. This information is to help you add more depth to those conversations.

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