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The clinicians in the middle
Where U.S. nurse practitioners and physician assistants work, how they feel about it, where they are moving, and what the evidence says about designing them into concierge and membership practices.
More than 461,000 licensed NPs. Nearly 190,000 board-certified PAs. The fastest-growing clinicians in American medicine.
And a large share of them are tired. About four in ten advanced practice registered nurses and one in three PAs report burnout in the latest national surveys.1,2 They did not train for years to become throughput.
Meanwhile, membership medicine changed shape. Advanced practice clinicians grew from about a third to about 40% of the clinicians in concierge and DPC practices between 2018 and 2023.3 The question for physician leaders is no longer whether NPs and PAs will be part of membership medicine. It is whether that happens by design or by drift.
Summary
Objective. To describe the employment settings, satisfaction, burnout and practice-model migration of U.S. NPs and PAs, and to assess the evidence for integrating them into concierge and membership-based practices.
Methods. Review of national certification, licensure and workforce surveys (AANP, NCCPA, NCSBN, HRSA), the AMA physician benchmark, and peer-reviewed literature, including Zhu et al. in Health Affairs (2025). Direct primary care is excluded from recommendations (see Brief No. 21) but cannot be separated from the underlying membership-practice data.
Results. Most NPs and PAs work in hospital-linked or group settings. Satisfaction is high, but burnout is substantial and varies by setting more than by credential. Advanced practice clinicians are the fastest-growing segment of the membership medicine workforce. Evidence on cost and quality when NPs and PAs carry independent panels is mixed.
Conclusion. Membership models can create the conditions associated with lower burnout, but outcomes depend on structure: defined roles, protected panels and clear physician leadership where physicians are present. The case is an inference from adjacent evidence and warrants direct study.
Hospitals employ about 42% of PAs, office-based private practice about 37%.4 NPs most often work in hospital outpatient clinics (14.3%), private group practices (10.4%) and inpatient units (10.0%); about 3.8% own a practice.5
The workforce, by the numbers
Burnout is real, and setting matters more than title
Burnout data for NPs and PAs are less mature than for physicians, and definitions vary. With that caveat, the pattern is consistent. The National Council of State Boards of Nursing reports that 40.3% of APRNs described burnout in 2024, improved from 2022 but still elevated.1 Earlier national estimates for NPs rose from 38.5% in 2019 to 54% in 2021.11 NCCPA reports 32.6% of PAs experiencing burnout in 2024, and in its prior report 44.9% of PAs planning to leave their position cited burnout.2,12
The number that matters most for practice designers is the spread by setting. PAs in office-based private practice report the lowest burnout, 30%. PAs in community health centers report the highest, 41.5%.2 That 11.5-point gap is produced by environment, not credential.
The drift toward membership models
The strongest data point in this review comes from Zhu and colleagues in Health Affairs (December 2025). Using linked national data, they found that concierge and DPC practice sites grew from 1,658 to 3,036 between 2018 and 2023, and clinicians from 3,935 to 7,021.14 Physicians fell from 67.3% to 59.7% of that workforce while advanced practice clinicians rose from 32.7% to 40.3%.7 Independent ownership fell from 84.0% to 59.7%, and about 60% of these clinicians still participated in Medicare, which suggests concierge or hybrid designs.3
Reporting on the study also noted that roughly 40% of NPs and PAs entering these practices had no previous employer in the data, compared with about one-fifth of physicians.15 That suggests many NPs and PAs enter membership care early in their careers rather than as a late-career exit, although the reason is not established.
Other destinations
Beyond concierge and DPC, national research on NP and PA migration remains limited. The best-documented shifts are these: PA participation in telemedicine rose from 9.2% in 2019 to 42.7% in 2023.12 Employer onsite clinics have long relied on advanced practice clinicians; a 2019 large-employer survey found PAs at 63% of onsite clinics and NPs at 34%.16 A 2026 qualitative study of NP primary care practice owners identified reimbursement differentials and credentialing delays as core barriers to ownership.17
Industry marketing frequently describes NPs moving into cash-pay aesthetics, weight management and IV therapy memberships. The trend is visible in the market but has not yet been measured nationally, so CMT reports it as an observed pattern rather than a quantified finding.
Evidence in tension
Research Brief No. 18 summarizes two decades of studies finding comparable outcomes for NPs and PAs in routine and chronic primary care, alongside the strongest contrary evidence. Because the contrary evidence bears directly on practice design, it is worth examining closely here.
The most cited counterpoint is an analysis by Hattiesburg Clinic, a large Mississippi multispecialty group, published by Batson, Crosby and Fitzpatrick in January 2022. In Medicare ACO data, patients whose primary clinician was an NP or PA carried higher per-member spending ($43 per month unadjusted, $119 risk-adjusted), made more emergency department visits, and physicians outperformed on nine of ten quality measures.18 The authors themselves described the work as an observational experience rather than a formal study, and it reflects a single system in which NPs and PAs managed their own panels.18
The most accurate synthesis is not that one side is right. It is that outcomes appear to depend heavily on structure: how panels are assigned, how escalation works, and how clinical leadership is organized. According to a physician advocacy group's summary, Hattiesburg responded by restructuring so every patient has a physician as primary care provider, with advanced practice clinicians working alongside.19 That is precisely the variable a well-designed membership practice controls.
The data do not say membership medicine cures NP and PA burnout. They say settings with more control and fewer handoffs have less of it, and that structure drives quality. Membership design is how you build those settings on purpose.
The case for membership design
Every practice-model debate goes wrong the same way: it casts one profession as the villain. That is not this brief. In this story, the NP or PA is the hero, the physician leader is the architect, and the villain is a system that measures care in fifteen-minute units.
The problem, on three levels
Externally, the clinician faces volume. Full-time NPs averaged 16 patients per day in AANP's 2020 survey; those in urgent care averaged 29.5 Internally, they feel like a line item, and about one in five NPs changes jobs each year.6 Philosophically, it is simply wrong that the clinicians who spend the most time with patients have the least control over how that time is structured.
Why membership models fit, from first principles
Strip the debate to fundamentals. A primary care relationship needs four things: clinician time, patient trust built through continuity, revenue that does not depend on visit volume, and systems that keep clinicians out of administrative work. Membership models address the third directly, because recurring fees decouple income from visit count. That creates room for the first two. Whether they deliver the fourth depends on execution.
For NPs and PAs specifically, three pieces of evidence point the same way. Office-based private practice already shows the lowest PA burnout.2 The membership sector is visibly absorbing advanced practice clinicians.3 And HRSA's projection of a primary care physician shortage alongside NP growth means physician-led concierge practices that want to extend hours, serve families or grow panels will increasingly need a team.9,10
An open research question. No peer-reviewed study yet measures burnout, satisfaction, cost or quality specifically for NPs and PAs working inside concierge or membership practices. The case above is drawn from the closest available evidence, and CMT identifies direct measurement of these outcomes as a priority for future research.
The plan
Learn the model
Understand the difference between concierge (retainer plus insurance billing), hybrid and fully direct-pay designs, and your state's scope-of-practice and title-disclosure rules, before you hire.
Build a defined team
Design NP and PA roles around continuity: named panels, protected visit length, clear escalation to the physician and shared after-hours coverage. Role clarity is what the U.K. learned the hard way.
Lead with transparency
Tell members exactly who will care for them and when. A membership promise is a trust promise. Members who expected a physician and got a surprise will cancel.
If practices drift
NPs and PAs are added as inexpensive capacity. Visit volume creeps back. Members notice. The corporate share of the sector keeps rising, and the relationship model that made membership medicine distinctive erodes from within.
If practices design
Physicians extend their reach without extending their hours. NPs and PAs work in the kind of setting associated with lower burnout. Members get more access without less relationship. The practice becomes a place clinicians stay.
For CMT and CMF. This is a Learn, Build, Lead story. A Concierge Medicine Forum session on designing the physician-led membership team should feature operators who have done it, with staffing ratios, member retention and clinician turnover data on stage. No vendors, no pitches.
Risks and blind spots
Three risks deserve equal airtime. Access and equity: the Health Affairs authors and others have raised concerns that membership growth may affect access for patients who can only use insurance-covered care.14 Consolidation: corporate-affiliated membership practices grew 576% in five years, which may reshape the sector's culture.3 Compliance: concierge fees charged to Medicare beneficiaries, NP and PA scope-of-practice rules, title-disclosure laws and state consumer-protection rules for membership agreements all vary. Practices should obtain qualified legal counsel.
How this brief relates to Brief No. 18
Brief No. 18 makes the broad, evidence-based case that NPs and PAs are a growing and often excellent part of primary care and of concierge medicine. This brief goes one level deeper, into where they work, how burnout varies by setting, and how physician leaders can design teams that hold up. CMT continues to cover NP- and PA-owned membership practices as a legitimate and growing part of the field.
How this brief was prepared
Design
Structured evidence review of national workforce surveys, agency projections and peer-reviewed literature, with claim-level verification. Searches were conducted September 25, 2026.
Derived figures
Counts of physicians and advanced practice clinicians in concierge and DPC practices were calculated by CMT by multiplying the published clinician totals by the published role shares in Zhu et al. (2025). They are rounded estimates and labeled as derivations.
Exclusion of direct primary care
DPC is excluded from this brief's recommendations for the reasons stated in Brief No. 21. It could not be excluded from the Zhu et al. data, which combine concierge and DPC practices.
Limitations
Burnout instruments differ across professions and surveys; comparisons are directional. NP satisfaction data are older and less standardized than PA data. Headcounts are not FTEs. The Hattiesburg analysis is observational and single-site; the comparable-outcomes literature summarized in Brief No. 18 has its own limitations. No study measures NP or PA outcomes specifically inside concierge practices.
Research support
Literature searches for this brief were supported by AI-assisted research tools. Every statistic is tied to the cited source, and derived figures are labeled. Concierge Medicine Today does not accept vendor sponsorship in exchange for coverage.
Disclaimer
This research brief is published by Concierge Medicine Today, LLC for educational and informational purposes only. It does not constitute medical, legal, financial, tax or accounting advice, and it should not be relied upon as such. Scope-of-practice rules, corporate practice of medicine doctrines, title-disclosure requirements, Medicare participation and concierge fee arrangements, and consumer-protection rules for membership agreements vary by state and jurisdiction and change frequently. Consult qualified legal, regulatory and financial professionals before making practice decisions.
Concierge Medicine Today is an independent leadership publication and industry convener. It does not endorse any practice model, company or vendor, and it does not disparage other models of care or other professions. References to organizations are informational and do not imply endorsement by or of those organizations.
Statistics are reported as published by the cited sources. Where CMT has derived, rounded or inferred a figure, the brief says so. Readers should consult original sources before citing any figure. Corrections are made openly: if you identify an error, contact the editors and it will be acknowledged and corrected.
© 2026 Concierge Medicine Today, LLC. All rights reserved.
References
- Nurse.org. APRN burnout and workforce recovery: what NCSBN's latest research tells us (analysis of the 2022 and 2024 National Nursing Workforce Surveys, Journal of Nursing Regulation). 2026. nurse.org
- National Commission on Certification of Physician Assistants. PA profession adapts to evolving health needs: 2024 Statistical Profile of Board Certified PAs. May 12, 2025. nccpa.net
- Zhu JM, et al. Growth in number of practices and clinicians participating in concierge and direct primary care, 2018 to 2023. Health Affairs. December 2025. doi:10.1377/hlthaff.2025.00656. healthaffairs.org; PubMed
- Clinical Advisor. NCCPA report outlines trends in PA profession (2022 practice settings). June 2024. clinicaladvisor.com
- AANP. 2020 National Nurse Practitioner Sample Survey. storage.aanp.org
- Earnings, job satisfaction, and turnover of nurse practitioners across employment settings. PMC10986281. ncbi.nlm.nih.gov
- MGMA. Snapshot: reactions and responses to the growth in concierge and direct primary care. December 30, 2025. mgma.com
- American Association of Nurse Practitioners. Nurse practitioners recognized nationwide during National NP Week. November 10, 2025. aanp.org. Also: A behind-the-scenes look at the 2025 nurse practitioner count. November 11, 2025. aanp.org
- Health Resources and Services Administration, National Center for Health Workforce Analysis. State of the Primary Care Workforce, 2025. bhw.hrsa.gov
- HRSA. State of the Primary Care Workforce, 2024 (hosted copy). iafp.org
- The Social Ecology of Burnout: a framework for research on nurse practitioner burnout. Nursing Outlook. 2024. nursingoutlook.org
- NCCPA. 2023 Statistical Profile of Board Certified PAs. May 2024. nccpa.net; full report PDF
- American Medical Association. Physician burnout rate continues to decline, falling to nearly 42%. April 16, 2026. ama-assn.org. Coverage: Fierce Healthcare, April 21, 2026. fiercehealthcare.com
- Johns Hopkins University Hub. Concierge medicine rising. December 18, 2025. hub.jhu.edu
- The Lund Report. Corporations are moving fast into direct care and concierge medicine. thelundreport.org
- SHRM. The pros, cons and possibilities of onsite health care (citing the National Business Group on Health 2019 Large Employers' Health Care Strategy and Plan Design Survey). shrm.org
- The facilitators and barriers of nurse practitioner primary care practice ownership: a qualitative analysis. 2026. PubMed
- Batson BN, Crosby SN, Fitzpatrick JM. Targeting value-based care with physician-led care teams. Journal of the Mississippi State Medical Association. January 2022. As summarized by the AMA: Amid doctor shortage, NPs and PAs seemed like a fix. March 17, 2022. ama-assn.org
- Physicians for Patient Protection (physician advocacy organization). A study in Mississippi concludes that non-physician care costs more. April 6, 2022. physiciansforpatientprotection.org