The History of Concierge Medicine: How Membership-Based Physician Practices Emerged and Evolved
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LAST UPDATED: 2026
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Concierge Medicine Today. "The History of Concierge Medicine: How Membership-Based Physician Practices Emerged and Evolved." CMT Knowledge Library. 2026. conciergemedicinetoday.net/knowledge-library
DISCLAIMER
This article is provided for educational and informational purposes only and should not be interpreted as medical, legal, financial, or regulatory advice. Healthcare practice models vary widely depending on jurisdiction, regulatory requirements, and individual physician circumstances. Physicians should consult qualified advisors when evaluating practice structures or contractual arrangements.
INTRODUCTION
Concierge medicine is a membership-based healthcare model in which patients pay a recurring fee to a physician or medical practice in exchange for enhanced services, smaller patient panels, and a more personalized care relationship.
The model first emerged in the United States during the 1990s, at a time when physicians and patients were increasingly confronting structural changes in the healthcare system — including growing administrative complexity, expanding managed care networks, and declining time available for physician–patient interaction. What began as a small number of independent experiments in retainer-based care has grown, over three decades, into a diverse and expanding category of medical practice that now includes independent physician practices, health-system affiliated programs, specialty concierge models, and hybrid approaches combining insurance billing with direct membership services.
Understanding the history of concierge medicine provides useful context for evaluating the model today — its origins, the pressures that shaped it, the generational changes it has undergone, and the direction in which it continues to evolve.
PART ONE: THE CONDITIONS THAT CREATED CONCIERGE MEDICINE
American Medicine Before the 1990s: Cash-Pay and the Personal Physician
For most of the twentieth century prior to the managed care era, the dominant model of American primary care was built on a direct relationship between a physician and the patients they served. Patients paid physicians directly for services rendered, insurance was used primarily for hospitalization and catastrophic care, and the physician's panel was constrained primarily by time and geography rather than by network contracts or administrative requirements.
Some experts trace the roots of cash-pay preventive medicine as far back as 1913, when a documented U.S. medical practice touted regular examinations delivered on an ongoing basis — regardless of medical necessity — as a superior form of prevention. The concept was envisioned in 1920 and 1921 as a U.S. worker health solution, designed to increase productivity and better protect employees (Eischen Law Office, 2025). This early model was protected by three federal statutes and substantial Medicare and OIG guidance — a legal framework that would later support the modern concierge structure.
What this era produced — before managed care reshaped the economics — was something physicians and patients would eventually spend decades trying to recreate: a physician who knew their patients deeply, could be reached when needed, and was accountable primarily to the patient rather than to an insurance system or hospital network.
The Rise of Managed Care and Its Discontents: 1970s–1990s
Beginning in the 1970s and accelerating through the 1980s and 1990s, the American healthcare system underwent a structural transformation driven primarily by the need to control costs. Health Maintenance Organizations and other managed care structures became the dominant financing model for employer-sponsored insurance, and their logic — emphasizing cost containment, network contracts, and utilization management — reshaped how physicians practiced medicine.
The rise of HMOs in the mid-1980s and into the early 1990s resulted in pressure for physicians to spend less time than they wanted with patients. Panel sizes grew. Appointment times shortened. Administrative requirements expanded. Physicians who had entered medicine to build long-term relationships with patients found themselves managing thousands of patients in high-volume practices, constrained by network rules and reimbursement structures that rewarded volume over relationship.
A widely cited time-motion study published in Annals of Internal Medicine in 2016 found that physicians in ambulatory practice spent nearly two hours on electronic health record and administrative tasks for every hour of direct patient care.¹
By the mid-1990s, a number of physicians had begun asking a question that would eventually give rise to concierge medicine: what would happen if a physician simply stepped outside this system — and built a practice structured entirely around the relationship?
PART TWO: THE FIRST GENERATION — BESPOKE CONCIERGE MEDICINE (1990S)
The Founding of MD² and the Birth of Retainer Medicine
Frustrated with overcrowded practices, rushed appointments, reactive care, and complex billing processes, Dr. Howard Maron joined Dr. Scott Hall to reimagine primary care. In 1996, the first MD² concierge medical office opened in Seattle, Washington.
Dr. Howard Maron was former physician to the Seattle SuperSonics. He appreciated the high level of care and attention he provided to the team, and wondered why people who were not star athletes could not also have a personal physician. At MD², there were two physicians per office, with each physician caring for just 50 families. MD² charged an annual retainer fee in the range of $13,200 to $20,000 per family.
Dr. Maron founded MD² based on the belief that delivering exceptional medical care must fundamentally revolve around, honor, and protect the most sacred of relationships — that between a physician and a patient. The core elements of the MD² model were present from the beginning: no-wait, unrushed, completely private visits that allowed physicians and patients to build strong relationships that reached beyond the practice walls.
MD² did not initially use the term "concierge medicine" to describe what it was doing. Dr. Maron preferred the phrase "highly attentive medicine." The term concierge would come later, applied by others to describe the growing category of retainer-based practices that followed in MD²'s wake.
The Characteristics of First-Generation Bespoke Care
What MD² established — and what CMT now refers to as first-generation or bespoke concierge medicine — was a model defined by several characteristics that distinguished it sharply from the managed care world surrounding it:
An extremely small patient panel — 50 families per physician — that allowed for the kind of familiarity that is structurally impossible at conventional panel sizes. Physicians knew not just their patients' medical histories but their families, their travels, their anxieties, and their lives.
A retainer fee structure that replaced insurance billing entirely, creating a direct financial relationship between patient and physician with no intermediary.
An emphasis on availability and accessibility — the physician reachable at any hour, for any concern, regardless of whether it required a formal appointment.
A deliberate focus on prevention, relationship, and the patient as a whole person rather than as a collection of billable diagnoses.
This first-generation model served a very specific patient population: ultra-high-net-worth individuals, executives, and families for whom the cost of the retainer was manageable and the value of the relationship was clear. It was not designed for broad access. It was designed to prove that a different kind of medicine was possible.
Early Academic Attention and Ethical Debate
As bespoke concierge practices began to attract attention in the early 2000s, the model sparked substantive debate within the healthcare community.
One of the earliest academic analyses of concierge medicine was published in JAMA in 2005, describing concierge medicine as a retainer-based practice model in which physicians charge patients an annual fee in exchange for enhanced services and physician accessibility, noting that these practices offered smaller patient panels, extended appointment times, enhanced physician familiarity with patients, preventive health planning, and coordination of specialty care.²
In 2002, HHS issued public guidance providing what many considered a meaningful green light for the retainer model as it related to Medicare compliance. The AMA drafted guidelines for what it then called "boutique" practices, reflecting institutional recognition that the model had become a real and expanding feature of the healthcare landscape.
CMT was founded in 2007 as the first independent trade publication dedicated to this field — the same year that the term "direct practice" first entered state legislation in Washington, clarifying that direct care practices were not affiliated with insurance companies under state law.
PART THREE: THE SECOND GENERATION — CONTEMPORARY CONCIERGE MEDICINE (2000S–2010S)
MDVIP and the Democratization of the Model
The second major chapter in the history of concierge medicine began in Boca Raton, Florida in 2000, when a group of physicians — including Robert Colton, MD, Edward Goldman, MD, and Bernard Kaminetsky, MD — founded MDVIP with a structurally different vision of what retainer medicine could be.
Where MD² had built around 50 families per physician at $13,000–$20,000 per year, MDVIP built around panels of up to 600 patients at dramatically lower annual fees. For $1,500 a year, the practice offered patients same-day appointments, home delivery of prescriptions, house calls, and 24/7 access. Critically, MDVIP opted to bill insurance in addition to charging a membership fee — a hybrid structure that made the model accessible to a far broader patient population, including Medicare beneficiaries.
Since its founding in 2000, MDVIP has achieved 100 consecutive quarters of growth. Today, the MDVIP network includes more than 1,400 affiliated physicians and over 430,000 members nationwide.³
MDVIP's growth — and the emergence of other practice management organizations like SignatureMD, founded in 2006 — marked the transition from first-generation bespoke concierge medicine to what CMT calls the contemporary or patient-centered medical (PCM) model. This second generation brought concierge medicine's core principles — smaller panels, enhanced access, longer appointments, preventive focus — to a broader and more economically diverse patient population.
The Contemporary Model's Structural Characteristics
Annual membership fees typically in the range of $1,500 to $5,000. Patient panels of 225 to 600 patients. Maintained participation in the insurance system for covered services, with the membership fee supporting enhanced access and services not reimbursed through insurance. By 2010, one quarter of all doctors operating with a concierge medicine model were affiliated with MDVIP.
The Parallel Development of Direct Primary Care
While the contemporary concierge model was expanding, a structurally distinct membership-based model was also developing: Direct Primary Care (DPC).
DPC differed from contemporary concierge medicine primarily in its relationship to insurance. Where most concierge practices maintained insurance participation for covered services, DPC practices typically refused insurance billing entirely — replacing it with a low monthly membership fee that covered most or all primary care services.
The first legislation recognizing direct care practices as distinct from insurance appeared in Washington State in 2007. By the 2010s, both models were growing simultaneously, serving overlapping but distinct patient populations and physician preferences.
Growing Concern About Physician Burnout
The sustained growth of membership-based models through the 2010s tracked closely with a growing body of research documenting the structural unsustainability of high-volume primary care practice. Research published in Mayo Clinic Proceedings documented rising levels of physician burnout associated with workload, administrative burden, and practice environment pressures.⁴ The Sinsky time-motion study showed physicians spending twice as much time on documentation as on direct patient care.¹ For the physicians who chose concierge medicine during this period, the motivation was often less about financial opportunity than about professional survival.
PART FOUR: THE THIRD GENERATION AND EXPANSION (2010S–PRESENT)
Direct Primary Care's Formalization
Through the mid-2010s, Direct Primary Care emerged as a formalized and growing movement — distinct from concierge medicine in structure but sharing its fundamental philosophy of direct, relationship-based care financed through patient membership rather than insurance reimbursement.
According to a 2024 AAFP data brief, 9% of family physicians reported operating a DPC practice — a significant increase from prior years — and 94% of DPC physicians were satisfied with their overall practice, compared to 57% of those not in a DPC practice. DPC physicians were also less likely to report burnout, with 49% reporting no level of burnout, compared to just 14% of non-DPC physicians.⁵
COVID-19 and the Acceleration of the Model
The COVID-19 pandemic, beginning in 2020, created conditions that accelerated physician interest in concierge and membership-based models. Physicians in high-volume traditional practices faced extraordinary demands during the pandemic period. Many experienced firsthand the fragility of fee-for-service revenue models when patient volume collapsed.
Concierge practices reported a zero percent pandemic closure rate across the SpecialDocs network of practitioners — a stark contrast to independent practices across the country that closed, accepted hospital employment, or retired early. Concierge doctors reported an increase of 21% in new patient volumes during the pandemic period, as patients sought direct physician relationships at a time when the healthcare system was under maximum stress.
SpecialDocs CEO Terry Bauer stated: "During the COVID-19 crisis, it became clearer than ever that our concierge medicine model provides a proven, sustainable path to stability and success for independent physicians."
Documented Growth: 2018 to 2023
Research published in Health Affairs in 2025 examined national data using novel linkages of public and proprietary sources. 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. The share of clinicians who were physicians declined from 67.3 percent to 59.7 percent, while the proportion of advanced practice clinicians increased — reflecting a broader workforce shift within the field.⁶
Market Scale
The U.S. concierge medicine market was valued at approximately $7.35 billion in 2024 and is projected to grow at a compound annual growth rate of over 10% annually through 2030, reaching an estimated $13.23 billion.⁷ The global market is estimated at $20.5 billion in 2025 and projected to reach $46.59 billion by 2035.⁸
Despite this growth, membership-based models remain a small fraction of total physician practice. CMT estimates that approximately 10,000 to 25,000 physicians or subscription-based programs currently operate in the United States — representing well under two percent of the practicing physician workforce.
PART FIVE: CONCIERGE MEDICINE TODAY AND LOOKING AHEAD
CMT's Three-Generation Framework
Three decades after Dr. Howard Maron opened the first MD² office in Seattle, concierge medicine encompasses a diverse range of practice structures. CMT's three-generation framework reflects the structural differentiation that has occurred within the field:
First generation — Bespoke concierge medicine: The original model, pioneered by MD² in 1996. Ultra-small patient panels (typically 50 families or fewer), very high annual fees ($13,200–$40,000+), serving ultra-high-net-worth patients. Designed around total physician availability and familiarity.
Second generation — Contemporary concierge medicine (PCM): The dominant model today, exemplified by MDVIP and similar networks. Panels of 225–600 patients, annual fees typically $1,500–$5,000, maintaining insurance participation for covered services.
Third generation — Direct Primary Care: A structurally distinct model that eliminates insurance billing entirely, replacing it with monthly membership fees ($50–$150/month), emphasizing simplicity, transparency, and operational independence from the insurance system.
What the History Tells Us
The forces that created concierge medicine in the mid-1990s have not been resolved. Physician burnout, administrative burden, primary care workforce shortages, and patient frustration with access constraints remain the defining conditions of American primary care in 2026.
According to the AAMC, the United States faces a projected shortage of up to 124,000 physicians by 2034, including between 17,800 and 48,000 primary care physicians.⁹ The AMA's 2025 data found that 41.9% of physicians reported experiencing at least one symptom of burnout.¹⁰
These are not new problems. They are the same problems that drove Howard Maron to open MD² in 1996. The model has grown for three decades not because of marketing or momentum, but because the structural conditions that made it necessary have, if anything, intensified.
SOURCES AND CITATIONS
Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice. Annals of Internal Medicine. 2016. DOI: 10.7326/M16-0961. acpjournals.org
Alexander GC, Kurlander J, Wynia MK. Physicians in Retainer ('Concierge') Practice. Journal of the American Medical Association (JAMA). 2005. jamanetwork.com
MDVIP. 100 Consecutive Quarters of Growth. Press release. February 2026. mdvip.com
Shanafelt TD et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians. Mayo Clinic Proceedings. 2022. mayoclinicproceedings.org
American Academy of Family Physicians (AAFP). Answers to Six Common Questions About Direct Primary Care. 2024 DPC data brief. Updated October 2025. aafp.org
Adashi EY et al. Growth In Number Of Practices And Clinicians Participating In Concierge And Direct Primary Care, 2018–23. Health Affairs. 2025;44(12):1473–1481. DOI: 10.1377/hlthaff.2025.00656. healthaffairs.org
Grand View Research. U.S. Concierge Medicine Market Size, Share & Trends Analysis Report. Projected CAGR 10.33%, 2025–2030. grandviewresearch.com
Towards Healthcare. Concierge Medicine Market to Grow USD 46.59 Bn by 2035. towardshealthcare.com
Association of American Medical Colleges (AAMC). The Complexities of Physician Supply and Demand: Projections from 2019 to 2034. aamc.org
American Medical Association (AMA). Physician Burnout Rate Continues to Decline, Falling to Nearly 42%.2025. ama-assn.org
Eischen Law Office. Cash Healthcare: Legal and Regulatory History. eischenlawoffice.com. 2025.
MD². Concierge Medicine Origins. md2.com/our-origins.
Dalen JE, Alpert JS. Concierge Medicine Is Here and Growing. American Journal of Medicine. 2017. amjmed.com
Kona Medical Consulting. COVID-19 Impact on Concierge Medicine Patient Volumes. 2020. Referenced in Vision Research Reports analysis.
Concierge Medicine Today. Industry Estimates — Concierge and Membership Medicine. 2026. conciergemedicinetoday.net
RELATED KNOWLEDGE LIBRARY ARTICLES
For a practitioner-focused overview with visual timeline, see the History section of the CMT Leadership Hub.
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