Why am I buying “healthcare,” when I really want “health”?
New ideas to align primary care to your goals instead of insurance shareholders
Do you ever feel like you’re settling for “medical care” when you really want to buy “health”? Think about your last primary care visit: You arrive after waiting two months, sit in a bland waiting room for longer than you hoped, only to get into an examination room to wait some more. Finally, after spending time with nurses who ask about your concerns but won’t ultimately be answering them, the provider arrives, has a 5-minute chat, suggests a pill, and warmly invites you back in 4 months to check on that with a hand on the door. Did you leave feeling like you paid a lot for a little? Not a satisfying experience, nor, frankly, an effective one. A better world is possible! (for some people).
Patients are a third wheel in the current system
The problem with this experience is that no one (except you) is organizing around health as the outcome. What is health to you? Maintaining a healthy weight, more energy, or dancing at your grandchild’s wedding? Nowhere in that list was “medical care.” What if there was a system where the key players were aligned around “health” as a goal, instead of “medical care”?
Primary care practices face pressure to see as many patients as possible each day because insurance companies reimburse practices on a per-patient basis. Insurers also reimburse more generously for medical tests and procedures than for visits and consultations. In short, long talks with patients simply do not pay.1
This is because insurance companies must answer to shareholders who are interested in short-run profitability. Insurer-provider financial arrangements are usually contracted over a period of 1 or 2 years only. For chronic illness and preventive care, this creates a barrier to optimizing health because preventing chronic illness has short-term costs but long-term benefits. Insurers face the short-term costs, but they don’t reap the long-term benefits. In the current financial arrangement, insurance companies answer to shareholders, and, in turn, physicians answer to the insurers’ reimbursement schedules.
As chronic disease grows in the U.S., our best candidate to improve long-term health is good primary care. Yet shortages in primary care are growing equally fast. In 2024, only 24.4% of US physicians are in the primary care specialties of Family Practice, General Internal Medicine, and Pediatrics.
Between reimbursement policies and doctor shortages, no one (except you) is organizing around your health as an outcome. Your doctor does not have time and is not paid to make sure you can dance at your grandchild’s wedding. He or she is paid to check your labs, ask you if you’re taking your statins, and then send you to the front desk to schedule a follow-up.
But what would happen if you paid your doctor directly?
Two emerging approaches for this problem are Concierge Care and Direct Primary Care. While differing slightly, both focus on enhancing primary care in exchange for a fixed, direct fee from the patient to the practice. Enhanced care can be quicker or easier access to clinical staff and more time spent with their doctor. These systems also enable more preventive care, including monitoring and testing, for patients with chronic conditions or at higher risk of future chronic conditions. Concierge Care is currently an add-on expense to existing traditional insurance, while Direct Primary Care can be used on its own as a partial substitute. Both are innovative because they use a new paradigm to align physicians’ financial payments with a patient’s goals.
The economic innovation of Concierge Care and Direct Primary Care lies in the importance of re-aligning primary care finances around the relationship between the patient and the physician and in enabling the use of one key input to producing health: time.
Time is important because healthcare is a “weird” product. When you (a consumer) buy a pair of jeans (made by a producer), you pull them off the rack, pay, and use them. In healthcare, this consumer-producer role is muddled. To manage a chronic disease, providers prescribe medication, but the patient needs to understand how to take the medication. Chronic disease also has an outsize lifestyle component. The provider can give instructions on healthy eating, smoking cessation, and exercise, but it is the patient-consumer who must implement these interventions. The patient is a co-producer of their health along with medical professionals.
For the provider and patient to improve health most effectively in a primary care setting, we need time for conversation. Conversations are where providers ensure that patients understand how to take their medication properly and, together, develop a plan for physical activity and diet. This all takes time. The time for conversation is made possible by changing the financial relationships between the patient, the insurers, and the provider. Concierge Care and Direct Primary Care facilitate this through the guaranteed income flow provided by the fixed fees paid by patients. Additional fixed income allows patients to benefit from greater attention and allows the physician to reorient around your health goals- not around reimbursement.
Time is also important in establishing trust with physicians. In 2025, JAMA reported that trust in physicians is the lowest in all 50 years of Gallup polling. Between 2019 and 2024, trust in physicians decreased by 12 percentage points, even after a surge in 2020.2 By allowing for increased time with physicians, these new models allow physicians to listen and gain trust, which in turn leads to better information sharing from the patient and increased compliance with medical instruction.
This new paradigm is popular with both patients and providers. From 2018 to 2023, the number of direct primary care and concierge practice sites grew by 83.1 percent and the number of clinicians participating in them by 78.4 percent.3 Patients benefit from more attention and opportunities to focus on their health goals in a collaborative way. Providers enjoy predictable, guaranteed income while seeing fewer patients and spending more time per appointment.
What’s the catch?
If this sounds great to you as a patient, physicians agree. On the provider side, physician burnout is rising, and health professionals who got into medicine to take care of patients in a meaningful way long for a way out. Concierge Care is increasingly attractive. Stepping back, however, you might notice that I have prescribed a fix for “There’s a shortage of doctors.” with “The solution is doctors should see fewer patients.” Before you cry “fuzzy math!” let’s walk through what success would look like under these new paradigms.
If patients and providers have effective conversations about prescription adherence and lifestyle adjustments, this will improve health outcomes. In our original “here’s a pill, come back in 4 months” scenario, we might be able to skip the 4 months if a better conversation gets to the best solution faster. When chronic disease is under control, patients don’t incur as many hospitalizations or specialist appointments and don’t develop other comorbid conditions that compound their existing poor health status. Importantly, a key reason for primary care shortages is the perception that salaries are not commensurate with the workload and stress. More enjoyable working environments would stop burnout and exit.
Catch #2: You have to pay for it yourself, for now.
Since concierge care currently exists in addition to your primary insurance, its subscribers tend to be wealthier and/or generally more concerned with their health. This isn’t necessarily different than wanting to buy time, since patients most willing to improve their health are most willing to invest in more time with providers, but it does have implications on the current mix of health conditions in this paradigm.
Concierge care likely has advantageous selection. This is a neat trick that can happen if the insurance structure is more useful to the healthy and less useful to the sick. (Insurance usually suffers from adverse selection- where sicker people are more likely to sign up.) Concierge care patients are generally wealthier than the average patient, and we know that income and health are positively correlated: richer people tend to have better health for a myriad of reasons, including more stable income, better long-term insurance coverage, and access to better food. This means positive outcomes of Concierge Care may also come from the types of patients in the system, not just the system itself.
Catch#3: Primary care isn’t all you need.
The struggle of creating a new paradigm is that sometimes the world around you needs to catch up. Concierge care has advantages, but its current implementation is simply as an expensive extra, not integrated into something you’re already paying for. Direct Primary Care is a standalone product, where you pay a fixed fee for an array of guaranteed primary care services. However, Direct Primary Care cannot stand alone if you also occasionally need specialty or emergency services. At the moment, you can supplement your Direct Primary Care with a catastrophic coverage style plan that would cover the extreme health events only. However, these plans are only available in the Marketplace Exchanges where prices are extremely high. Direct Primary Care presents a better model for primary care, but it cannot yet easily integrate into the health system around it.
Looking toward the future
Concierge Care and Direct Primary Care remind us that our current system misaligns incentives. Although health is created between the patient and the provider, funding goes through insurers. Realigning financial incentives could have a big impact in certain groups by reducing waste and excess, ineffective spending.
High-impact beneficiaries seem to be on the extremes of the distribution. One is patients who are actively focused on improving their long-term health. The other is patients with multiple chronic conditions that would benefit from coordination and real conversations about gradual lifestyle improvement, rather than expensive ramp-ups of siloed specialty interventions. For both these groups, there’s money on the table if they swapped access to more and unnecessary care in exchange for a more effective time-centered approach. Patients focused on long-term goals are willing to pay more to buy “health” (and, in fact, have already in these approaches) and better management of chronic conditions in at-risk populations drastically reduces costs in the long-term through fewer ED visits and specialty interventions. Meeting in the financial middle is possible for both.
The core insight is that insurers don’t gain financially from you dancing at your grandchild’s wedding, so they don’t fund a health experience that leads to that. But that’s what you want, and that’s what an aligned system would provide: health, rather than healthcare.
Hempel, Susanne et al., “Primary Care Productivity: Findings from the Literature and Perspectives from a Stakeholder Panel” RAND Corporation Research Report, 2021.
Alsan M, Cutler DM. Prescription for Division—Healing the Growing Gap in Physician Trust. JAMA Health Forum. 2025;6(12); e256765.
Zhu et al. “Growth In Number Of Practices And Clinicians Participating In Concierge And Direct Primary Care, 2018–23” Health Affairs, Vol 44 No. 12: December 2025.