The History of Concierge Medicine
Patients paid their doctors directly long before anyone said "concierge." This brief traces how that old idea returned in 1996, how federal rules and professional ethics shaped it, why direct primary care grew up as a separate model, and what the newest national data show about where membership medicine stands in 2026.
Updated October 2026: rebuilt with an expanded history back to 1929, a clearer guide to the practice models, two timelines, evidence-type labels and funding disclosures for every source. Corrects the journal for the 2005 Alexander study (Journal of General Internal Medicine, not JAMA). Adds the DocPreneur Leadership Podcast episode with health care attorney James Eischen, Esq.
Start here: the questions this brief answers
Direct payment to physicians is old; prepaid insurance only became the norm after 1929 and World War II. The modern concierge model began with MD² in Seattle in 1996, grew under federal guidance that the fee may not cover what Medicare already pays for, and stayed small for years (146 physicians identified in 2005). Direct primary care grew alongside it as a different, lower-fee, insurance-free model with its own state laws. A December 2025 national study found concierge and DPC practice sites combined grew 83.1% from 2018 to 2023, while critics question the effect on spending and access.
When did concierge medicine begin?
The model most sources point to is MD², opened in Seattle in 1996. Direct payment itself is much older: before prepaid plans, most patients paid their doctors and hospitals directly.
Go to the full answer ↓Is direct primary care the same thing?
No. Concierge practices commonly charge a membership fee and keep billing insurance and Medicare. DPC usually charges a lower monthly fee, does not bill insurance, and is governed in many states by its own statute.
Go to the full answer ↓Is a concierge fee allowed for Medicare patients?
Federal guidance since the early 2000s says retainer arrangements are allowed as long as the fee is not an extra charge for services Medicare already covers. Structure matters, so physicians should confirm theirs with counsel.
Go to the full answer ↓How big has it become?
A Health Affairs study counted 3,036 concierge and DPC practice sites in its 2023 national sample, up from 1,658 in 2018. Roughly 60% appeared to be concierge, by the authors' estimate.
Go to the full answer ↓What do critics say?
The strongest critique, a 2023 Journal of Health Economics study, found higher spending and no change in mortality among patients who joined converting practices. Supporters point to time, access and physician sustainability.
Go to the full answer ↓Part 1 · 1900s to 1995
Before the name: from paying the doctor to paying the plan
Concierge medicine is often described as new. Its payment idea is not. What changed in the twentieth century was who stood between the patient and the physician.
- 1929Prepaid care begins
- 1965Medicare and Medicaid
- 1996First concierge practice
- 2000National networks form
- 2005GAO counts 146 physicians
- 2007First direct practice law
- 2010ACA names DPC homes
- 2017Closures and consolidation
- 2025Growth data and HSA law
- 2026DPC laws in 35+ states
The overview above is simplified. The detailed, sourced timeline is in Part 3.
A month: what Dallas teachers prepaid in 1929 for up to three weeks of hospital care under the Baylor Plan, the model for Blue Cross.1
Practice InsightWartime wage controls did not count health benefits as wages, so employer-sponsored insurance spread and became the American default.1
Practice InsightMedicare and Medicaid signed into law on July 30. Medicare rules later define what a concierge fee may not cover.2
Policy and LawBy the 1990s, most primary care in the United States was paid through insurers, employers or Medicare, visit by visit. Physicians who later built membership practices described the same frustrations: crowded schedules, short visits and growing paperwork. The idea they returned to was simple and old. Let the patient pay the physician directly, and use that relationship to buy time.
Strip away the labels and every model in this brief answers one question: who pays the primary care physician, for what, and how much time does that payment buy? Insurance pays per visit. A membership fee pays for access and time. The history is largely the story of physicians testing different answers inside the rules of their era.
Part 2 · The models, clarified
One umbrella, several structures, and one different model
"Concierge," "boutique," "retainer," "membership" and "private" medicine are used loosely. Federal researchers in 2010 sorted retainer practices into three structures. CMT adds two neighbors that are often confused with them.3
| Model | What the fee pays for | Insurance and Medicare | Main rules to know | Evidence type |
|---|---|---|---|---|
| Fee for non-covered servicesConcierge | A periodic fee for services and access insurance does not cover, often an extended annual physical, longer visits and direct phone access. | Keeps billing insurance and Medicare for covered visits. | The fee may not be an extra charge for Medicare-covered services; the AMA asks for clear separation of the fee from billed care.4, 5, 6 | Policy and Law |
| Hybrid or segmentedConcierge | Some patients pay a membership fee for added services; others stay in the traditional practice. | Bills insurance for both groups. | AMA ethics guidance applies to mixed practices: patient choice must be voluntary and care standards cannot differ for covered services.3, 6 | Policy and Law |
| Fee for careConcierge | The fee covers most primary care services in the office. | May not bill insurance; some physicians opt out of Medicare. | Raises state insurance law and Medicare opt-out questions that depend on structure and state.3 | Population Data |
| Direct primary careA different model | A periodic, usually monthly, fee for a defined set of primary care services. | Does not bill third parties fee for service. | State DPC statutes in many states; a federal ACA provision on DPC medical homes; and, from 2026, an HSA rule with a monthly fee cap.7, 8, 9 | Policy and Law |
| Executive health | Comprehensive exams and coordination, often paid by an employer and often run by health systems. | Varies by program. | Not a single legal category. CMT includes it because it shares the direct-pay idea and is often confused with concierge medicine. | CMT reading, not research |
Mean patient panel of retainer physicians in a 2005 national survey, compared with 2,303 for nonretainer physicians.10
Practice InsightPatients per physician among retainer physicians interviewed for MedPAC in 2010, compared with over 2,000 before they converted.3
Population DataAverage monthly concierge fee in a 2015 national review of practice prices. Fees vary widely; this is one study's average.11
Practice InsightDirect primary care · a different model · the legal path DPC took
The figures below describe direct primary care, not concierge medicine, and are shown separately for context only.
- 2007Washington passes the first direct practice law, stating registered direct practices are not insurers.7 Policy and Law
- $77.38Average monthly DPC fee in the same 2015 national review.11 Practice Insight
- 35+ statesHave laws saying DPC agreements are not insurance, according to the Direct Primary Care Coalition (2026).12 Industry Research
- $150 / $300Monthly cap for individual and family DPC fees payable from an HSA, starting January 1, 2026.9 Policy and Law
"Let's focus on substance, not labels."
James Eischen, Esq., health care attorney, at an American Academy of Private Physicians conference, April 2015, as reported by CMT.13
Model sorter: which structure does a practice resemble?
Three questions. This sorts by structure only. It is not a legal determination; the label a practice uses can carry Medicare, tax and state insurance consequences, so confirm with counsel.
1. Does the practice bill insurance or Medicare for office visits?
2. Do all of the physician's patients pay the membership fee?
3. Is the practice registered or organized under a state direct primary care law?
Part 3 · 1929 to 2026
The full timeline
Every entry is sourced and labeled by evidence type. Direct primary care entries are boxed with a dashed border because DPC is a different model. Use the filters to follow one thread.
-
Before 1929
Patients pay the doctor directly
Before prepaid plans spread, patients and families generally paid physicians and hospitals themselves, and unpaid hospital bills were a common problem. This is the long tradition that today's membership models echo.1
-
1929
The Baylor Plan
Dallas schoolteachers prepay 50 cents a month for up to three weeks of care at Baylor University Hospital. The idea spreads, and by 1940 several of these prepaid plans operate under the Blue Cross banner.1
-
1940s
Insurance moves to the workplace
Wartime wage controls did not count employer-paid health premiums as wages, so employers competed for workers with health benefits. Paying for care through an employer plan becomes the American norm.1
-
1965
Medicare and Medicaid
President Lyndon B. Johnson signs the law creating Medicare and Medicaid on July 30, 1965. Medicare rules later shape what a concierge fee may and may not cover.2
-
1996
-
1997
-
2000
MDVIP is founded
MDVIP is founded in Boca Raton, Florida, and grows into a national network of affiliated physicians using a membership fee alongside insurance billing.18
-
2000
A hospital tries the model
Virginia Mason in Seattle opens what a law firm primer describes as the first hospital-based monthly fee practice, an early sign that health systems would adopt variations.19
-
2002 to 2004
-
Early 2000s
-
2005
-
2007
An independent trade publication
Concierge Medicine Today launches to cover concierge, retainer, private and direct care medicine.13
-
2007
-
2009
A consumer products company buys in
Procter & Gamble acquires MDVIP. Summit Partners had held a minority stake since 2004.21
-
2010
Direct primary care · a different model
The ACA names DPC medical homes
The Affordable Care Act lets qualified health plans offer coverage through a direct primary care medical home.8
-
2010
-
2014
Private equity era begins
Summit Partners acquires MDVIP from Procter & Gamble. The network reports more than 700 affiliated physicians and over 200,000 patients.18
-
2016
AMA ethics code modernized
Opinion 8.055 on retainer practices is renumbered as Opinion 11.2.5 in the modernized Code of Medical Ethics.6
-
2017
-
2017
-
2021
A larger buyout
Goldman Sachs Asset Management and Charlesbank Capital Partners agree to acquire majority ownership of MDVIP, which reports more than 1,100 physicians and 357,000 patients.26
-
2023
The strongest critique
A Journal of Health Economics study of physicians who converted to concierge practice finds higher spending for patients who enrolled and no change in mortality.27
-
2025
Direct primary care · a different model
DPC meets the HSA
The One Big Beautiful Bill Act and IRS Notice 2026-05 let people with HSAs pay qualifying DPC fees, capped at $150 a month for one person and $300 for a family, starting January 1, 2026.9
-
2025
-
2026
Direct primary care · a different model
State DPC laws pass 35
The Direct Primary Care Coalition reports that more than 35 states now have laws saying DPC agreements are not insurance.12
-
2026
The legal history, told by a practitioner
On CMT's DocPreneur Leadership Podcast, health care attorney James Eischen, Esq. traces cash-pay care from executive health through concierge medicine and DPC.30
Part 4 · Drivers and debate
Why it grew, and what the critics say
Physicians who moved to membership models usually describe a time problem. The research backs up the time problem. It is less settled on whether membership models are the right answer for the health system as a whole.
Where an hour of patient care goes
Ambulatory physicians observed in a 2016 time and motion study, hours of work per hour of direct patient care
Physicians reporting at least one symptom of burnout
National physician burnout study series
The debate, stated fairly
Higher spending, no mortality change
Studying physicians who converted to concierge practice, Leive, David and Candon found patients who joined had health spending over 25% higher than a comparison group one year later, with no change in mortality. Neighborhood income predicted enrollment more than health status did.27
Population DataThis is CMT's editorial reading, not a research finding. The 2023 study examined physicians converting to concierge practice and their Medicare patients, so it does not settle the question for every model, and DPC was not studied. It does show that "more time" and "better outcomes" are different claims, and that physicians should not promise the second without evidence. The fair summary: the time problem is well documented; the system-wide effects of membership models are still being measured.
Part 5 · 2026
Where it stands now
Counting membership practices has always been hard, because no license or registry defines "concierge." Each count below uses a different method, and they should not be added or compared directly.
Share of those sites the authors estimated were concierge rather than DPC, using Medicare billing as a proxy.29
Population DataGrowth in membership medicine, 2018 to 2023
Membership medicine (concierge and DPC combined); the concierge share was not reported separately in these counts
One national network's growth
MDVIP affiliated physicians as reported in ownership announcements
CMT estimates 8,000 to 12,000 concierge and membership-based practices nationally. This is a CMT field estimate; the method is not published, it uses a broader definition than the Health Affairs sample, and it should be read as an editorial estimate rather than a count.33 Industry Research
Three shifts to watch
Fewer independents
The Health Affairs study reported a large rise in corporate-affiliated concierge and DPC practices, from a small base, and fewer independently owned ones.28, 29
Population DataMore NPs and PAs
Advanced practice clinicians are a growing share of membership practices, which changes what "direct access to your physician" means.28
Population DataDPC's HSA rule
The 2026 HSA rule is written for DPC arrangements. Whether a given concierge membership could qualify is a tax question for counsel, not an assumption.9
Policy and LawFurther listening · DocPreneur Leadership Podcast · July 16, 2026
The Origins of Cash-Pay Healthcare in America: From Concierge Medicine to DPC and Beyond
California health care attorney James (Jim) Eischen, Esq., of Eischen Law Office, walks through the history of cash-pay care, from executive health to concierge medicine, DPC and lower-cost primary care, and the compliance questions each raises. One practitioner's perspective, offered as context and not as legal advice.30 Practice Insight
Disclosure: Mr. Eischen is a longtime contributor to Concierge Medicine Today. His firm advises private fee practices. No payment was exchanged for this listing.
Learn → Build → Lead
Using this history
Learn
Know which structure you are describing before you describe it. Concierge and DPC differ in billing, Medicare status, tax treatment and state law, and the history explains why.
Build
The models that lasted kept the fee clearly separate from covered care, kept panels sized to the promise, and built a funding base that did not depend on one lender or one client.
Lead
Take the critics seriously in public. Physicians who can explain the access and spending questions, and what their own practice does about them, build trust beyond their panel.
Methods
Methods, limitations and evidence types
This brief updates the March 2026 edition. CMT checked each timeline entry against an original or primary source where one was available, including federal statutes, GAO and MedPAC reports, the AMA Code of Medical Ethics, state insurance regulator reports, peer-reviewed journals and company press releases. Entries from CMT's 2022 history archive were kept only where they describe CMT's own reporting or could be confirmed elsewhere. Concierge medicine and direct primary care were kept separate throughout: DPC-only figures appear only in dashed DPC boxes, and combined figures are labeled "concierge and DPC combined." Historical accounts drawn from news reports and secondary histories are labeled Practice Insight.
Every key finding is labeled by evidence type. Labels describe the type of evidence, not its value. Each type answers different questions. Funding is disclosed on every source.
Randomized trials and systematic reviews.
Best for: cause and effectLarge observational studies and government data.
Best for: trends at scaleSurveys, smaller studies and expert consensus.
Best for: real-world experienceCompany-sponsored or company-reported data that is not peer-reviewed.
Best for: early signals and operating dataStatutes, regulation and official guidance.
Best for: what is requiredWhat we don't know
- How many concierge practices exist today. No registry defines the model, and published counts use different methods.
- Whether membership models change health outcomes. No randomized trial has tested concierge medicine against traditional primary care.
- How many membership practices have closed. Closures are not tracked nationally.
- The original documents for some early milestones, including the 2002 federal memoranda, which CMT confirmed through later government reports rather than the memoranda themselves.
How to cite this brief
Concierge Medicine Today. "The History of Concierge Medicine." CMT Research Brief No. 13, Version 2.0, October 2026.
External review: This brief has not been externally reviewed. Corrections: CMT corrects errors promptly and notes the change in the update line. Send corrections to the CMT editorial team.
Related CMT Research Briefs
References
Sources
- Rhodes K. "From Loophole to Mandate: Federal policies have fostered employment-based health insurance." Econ Focus, Federal Reserve Bank of Richmond, First Quarter 2014. richmondfed.orgFunding: federal (Federal Reserve Bank of Richmond)
- Centers for Medicare & Medicaid Services. "CMS' program history: Medicare & Medicaid." CMS.gov, accessed October 2026. cms.govFunding: federal (CMS)
- NORC at the University of Chicago and Georgetown University. "Retainer-Based Physicians: Characteristics, Impact, and Policy Considerations." Contractor report for the Medicare Payment Advisory Commission (MedPAC), No. 10-9, October 2010. medpac.govFunding: federal (MedPAC contract)
- Medicare.gov. "Concierge care." Coverage page, accessed October 2026. medicare.govFunding: federal (CMS)
- U.S. Government Accountability Office. Physician Services: Concierge Care Characteristics and Considerations for Medicare. GAO-05-929, August 12, 2005. gao.govFunding: federal (GAO)
- American Medical Association. Code of Medical Ethics Opinion 11.2.5, "Retainer Practices" (formerly Opinion 8.055; renumbered in the 2016 modernized Code). code-medical-ethics.ama-assn.orgFunding: not stated (published by the AMA)
- Washington State Office of the Insurance Commissioner. "Direct practices in Washington state: Annual report to the Legislature." December 1, 2025. (Chapter 48.150 RCW, enacted 2007 as E2SSB 5958.) insurance.wa.govFunding: state (Washington OIC)
- Patient Protection and Affordable Care Act, Pub. L. 111-148, sections 1301(a)(3) and 10104(a) (2010), codified at 42 U.S.C. 18021(a)(3). Via Legal Information Institute, Cornell Law School. law.cornell.eduFunding: not applicable (federal statute)
- One Big Beautiful Bill Act, Pub. L. 119-21 (July 4, 2025), and IRS Notice 2026-05 (December 9, 2025). Summary via Groom Law Group, "A Big, Beautiful Break for HSAs," December 2025. groom.comFunding: not applicable (federal law and IRS guidance); summary by a law firm
- Alexander GC, Kurlander J, Wynia MK. "Physicians in Retainer ('Concierge') Practice: A National Survey of Physician, Patient, and Practice Characteristics." Journal of General Internal Medicine, December 2005;20(12):1079 to 1083. doi:10.1111/j.1525-1497.2005.0233.x. (Listed as JAMA in the March 2026 edition of this brief; corrected.) doi.orgFunding: not stated in materials CMT reviewed
- Eskew PM, Klink K. "Direct Primary Care: Practice Distribution and Cost Across the Nation." Journal of the American Board of Family Medicine, November to December 2015. Summary via KFF Health News, June 2017. kffhealthnews.orgFunding: not stated in materials CMT reviewed
- Medical Economics. "Direct primary care 'at an inflection point' as doctors, patients, employers catch on." July 21, 2026. Figure attributed to the Direct Primary Care Coalition. medicaleconomics.comFunding: not stated (news report quoting an advocacy coalition)
- Concierge Medicine Today. "History of Concierge Medicine (1996 to 2022)." CMT Knowledge Center, Summer/Fall 2022 edition. conciergemedicinetoday.orgFunding: Concierge Medicine Today (self-published; no outside funder)
- MD². "Our Origins." Company website, accessed October 2026. md2.comFunding: not stated (company website)
- Associated Press. "Doctors pioneer 'concierge care'." Published via HeraldNet (Everett, WA), 2001. heraldnet.comFunding: not stated (news report)
- Harvard Medical School. "Direct Primary Care: A New Brew in Seattle." HMS News, undated (circa 2008). hms.harvard.eduFunding: not stated (university news report)
- Family Practice News, via The Hospitalist. "Physicians Tailor Their Concierge Care Practices." Undated (mid-2000s). community.the-hospitalist.orgFunding: not stated (news report)
- Summit Partners. "Summit Partners to Acquire MDVIP." Press release via GlobeNewswire, May 2, 2014. globenewswire.comFunding: not stated (company press release)
- Higgs Fletcher & Mack LLP. "Beginners Private Medicine Transition Considerations: A Private Medicine Primer." Presentation, 2015. higgslaw.comFunding: not stated (law firm presentation)
- Carnahan SJ. "Law, Medicine, and Wealth: Does Concierge Medicine Promote Health Care Choice, or Is It a Barrier to Access?" Stanford Law & Policy Review, 2006. Cites AMA Code of Medical Ethics Opinion 8.055, Retainer Practices (2004 edition). law.stanford.eduFunding: not stated
- Summit Partners. "MDVIP" portfolio page, accessed October 2026. summitpartners.comFunding: not stated (company website)
- American Medical News. "Concierge medicine a mere blip on Medicare radar." September 30, 2010. Summary of the MedPAC contractor report. amednews.comFunding: not stated (news report published by the American Medical Association)
- GeekWire. "Qliance healthcare startup cites lender fraud for sudden shutdown as patients are left in the lurch." May 19, 2017. geekwire.comFunding: not stated (news report)
- KFF Health News. "Despite A Growing Appetite, Buffet-Style Flat-Fee Clinics Shutter In Seattle." June 2017. kffhealthnews.orgFunding: not stated (news report)
- Leonard Green & Partners. Announcement of majority ownership of MDVIP from Summit Partners, November 2017. leonardgreen.comFunding: not stated (company press release)
- Charlesbank Capital Partners. "Goldman Sachs Asset Management and Charlesbank Capital Partners to Acquire Majority Ownership of MDVIP from Leonard Green & Partners and Summit Partners." Press release, August 19, 2021. charlesbank.comFunding: not stated (company press release)
- Leive A, David G, Candon M. "On Resource Allocation in Health Care: The Case of Concierge Medicine." Journal of Health Economics, July 2023. Summary via Penn LDI, September 18, 2023. ldi.upenn.eduFunding: not stated in materials CMT reviewed
- Zhu JM, Marsh T, Polsky D, Huntington A, Song Z. "Growth In Number Of Practices And Clinicians Participating In Concierge And Direct Primary Care, 2018 to 23." Health Affairs, December 2025;44(12). doi:10.1377/hlthaff.2025.00656. Site counts via Medical Economics, August 27, 2026; clinician counts via TechTarget, December 2025. healthaffairs.orgFunding: not stated in materials CMT reviewed
- Physicians Practice. "Concierge and direct primary care are booming, but corporatization and access questions are close behind." Interview with Jane Zhu, MD, January 21, 2026; and "Concierge and direct primary care practices surge nationwide," December 19, 2025. physicianspractice.comFunding: not stated (news report)
- Concierge Medicine Today Editorial Team. "The Origins of Cash-Pay Healthcare in America: From Concierge Medicine to DPC and Beyond." DocPreneur Leadership Podcast, July 16, 2026. Guest: James Eischen, Esq., Eischen Law Office. conciergemedicinetoday.orgFunding: not stated (podcast produced and published by Concierge Medicine Today; guest's firm advises private fee practices)
- Sinsky C, Colligan L, Li L, et al. "Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties." Annals of Internal Medicine, 2016. acpjournals.orgFunding: not stated in materials CMT reviewed
- Stanford Medicine. "Doctor burnout rates: what they mean." April 2025. Summary of the national physician burnout study series (Stanford Medicine, Mayo Clinic, American Medical Association). med.stanford.eduFunding: not stated (university news report on a multi-institution study)
- Concierge Medicine Today. Field estimate of concierge and membership-based practices, CMT Media Desk. conciergemedicinetoday.netFunding: Concierge Medicine Today (self-conducted; no outside funder)
Disclaimer
This brief is published by Concierge Medicine Today for educational and informational purposes only. It is not medical, legal, tax, financial or accounting advice. Readers should consult qualified professionals before making practice, legal or business decisions.
Concierge Medicine Today is an independent publication. It accepts no payment for favorable coverage, does not favor one practice model over another, and discloses the funding of every source it cites. Company-reported figures are labeled as such and have not been independently verified.
CMT works to keep this content accurate and current, but it is not without possible error or omission. © 2007 to 2026 Concierge Medicine Today, LLC. All rights reserved.