While physicians debate which cash-pay model is the future, a significant and largely untapped opportunity is sitting right in front of the industry — and the practitioners positioned to take it may not be who you expect. This is that conversation.

Episode Overview

In one of the most comprehensive episodes in DocPreneur Leadership Podcast history, host Michael Tetreault takes an honest, evidence-based, and encouraging look at the cash-pay and subscription-based primary care landscape — who it serves, how it works, where it’s heading, and what every physician and advanced practice clinician needs to understand before making a career-defining decision.

This episode doesn’t take sides. It takes a clear-eyed look at the full picture — including the parts that don’t always make it into the conference keynote.

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What’s Covered

The Foundation

Not all subscription-based primary care models are the same. Two models operating in this space share surface-level similarities but are structurally distinct businesses with different economic logic, different patient populations, and different long-term trajectories. Understanding which one you’re considering — and why — changes everything about how you plan.

A Lesson From Healthcare History

Before committing to any practice model, it helps to understand what happened to the movements that came before it. This episode traces three instructive parallels: the micropractice and ideal medical practice movement of the early 2000s; the decades-long fight for healthcare price transparency and what happened when physicians finally got it; and the rise and reality check of retail health — what scaled, what didn’t, and why. The common thread in every model that has achieved durable scale in American healthcare is the same: structural fit with the economic environment, not ideological purity.

Two Pathways, One Brand Name

The episode walks through both economic models in the cash-pay primary care space — the purist, cash-only, no-insurance model and the employer-integrated model — explaining how each works, who each serves, and what the financial picture actually looks like for physicians considering either path. The revenue math is done out loud. The sustainability data from peer-reviewed research is cited. The patient demographic fit for each model is examined honestly and specifically.

Who Each Model Serves — and Where Other Models Fit Better

A detailed breakdown of the patient populations each model genuinely serves well — and an honest, evidence-based look at the patient populations where other models may be a better structural fit. Including Medicare-eligible patients, patients with complex chronic disease, lower-income households, and employees of small and mid-sized businesses.

The Overlooked Opportunity — NPs, PAs, and Advanced Practice Clinicians

One of the most significant and under-explored opportunities in subscription-based healthcare delivery today is the direct-care model as a pathway for nurse practitioners, physician assistants, and other advanced practice clinicians. The evidence on NP and PA-led primary care outcomes is strong and peer-reviewed. The physician shortage projections make the need urgent. And the organizational infrastructure for advanced practice clinician-led direct-care practices is largely unbuilt — which means the opportunity belongs to whoever moves first.

The Organizational Landscape

An honest look at what the multiplicity of organizations, coalitions, and alliances in the cash-pay primary care space tells us — and what research on professional association dynamics says about the long-term implications of organizational fragmentation for legislative effectiveness and individual practice planning.

One Brand, Two Directions

Drawing on four documented historical parallels from the history of American medicine — the AMA and managed care, osteopathic medicine’s identity divide, family medicine’s emergence as a separate specialty, and the micro-practice movement — the episode makes the case that two communities with genuinely different economic interests and regulatory priorities currently sharing a brand name may, consistent with historical precedent, find their own distinct professional homes over time. Presented as pattern recognition grounded in verified historical evidence — and as practical planning context for physicians building practices today.

The Tax and Structuring Update

A clear, practical summary of the 2025 “One Big Beautiful Bill” Act changes — effective January 2026 — and what they mean for HSA eligibility of cash-pay membership fees. What qualifies, what doesn’t, and why legal counsel is essential before making any representations to patients about tax-advantaged payment options.

Eight Questions Before You Commit

A practical pre-decision checklist — eight specific questions every physician or advanced practice clinician should be able to answer clearly before committing to any cash-pay practice pathway.

Key Takeaways

• Cash-pay primary care and concierge medicine are not the same model, do not serve the same patient populations, and should not be evaluated as interchangeable alternatives.
• The purist cash-pay model has grown from approximately 100 practices in 2009 to over 2,100 by 2023 — real and meaningful growth. Peer-reviewed research has documented consistent financial sustainability challenges, particularly in lower-income markets and solo practice settings.
• The employer-integrated pathway has stronger structural sustainability — multiple revenue streams, embedded benefit relationships, and documented employer cost reductions of 12 to 20 percent over three to five years.
• A December 2025 Johns Hopkins study found concierge and cash-pay primary care practices combined grew 83.1 percent between 2018 and 2023. The employer-integrated model is the primary driver of that growth trajectory.
• Concierge medicine — particularly the PCM model — is not retreating. The global concierge medicine market is projected to surpass $34 billion by 2032.
• The National Academy of Medicine’s 2021 Future of Nursing report, AAMC physician shortage projections, and peer-reviewed NP/PA outcomes research collectively point to advanced practice clinician-led direct-care models as one of the most significant underexplored opportunities in subscription-based healthcare delivery.
• Models that have achieved durable scale in American primary care share one characteristic: structural fit with the economic environment, not independence from it.

Sources and Citations

Micropractice and Practice Model History Moore, G. (2002). Family Medicine. | Moore, G. & Showstack, J. (2003). Health Affairs. | AAFP TransforMED Initiative. (2006). aafp.org | Nutting, P.A. et al. (2010). Annals of Family Medicine. | Rittenhouse, D.R. et al. (2009). New England Journal of Medicine.

Price Transparency Research Pathak, Y. & Muhlestein, D. (2024). West Health Institute / Gallup. pmc.ncbi.nlm.nih.gov | Parente, S.T. (2023). Inquiry. pmc.ncbi.nlm.nih.gov | ScienceDirect. (2025). Systematic Review on Price Transparency Outcomes. sciencedirect.com

Retail Health Fein, A.J. (2017). Drug Channels. drugchannels.net | CNBC. (2024). cnbc.com | Healthcare Finance News. (2023). healthcarefinancenews.com | MedCity News. (2023). medcitynews.com

Cash-Pay and Subscription Primary Care Market Data MedCity News. (March 2026). medcitynews.com | Johns Hopkins. (December 2025). As cited in MedCity News, 2026. | Liaw, W. et al. (2024). Journal of General Internal Medicine. springer.com | Lujan, D.Y. (2025). KevinMD. kevinmd.com | Doan, L. et al. (2019). Family Medicine. | Eskew, P.M. & Klink, K. (2015). Health Affairs. | Tseng, P. et al. (2018). JAMA Internal Medicine. | Medscape Physician Compensation Report. (2023). medscape.com

Employer-Integrated Model Spann, S.J. et al. (2020). Journal of Occupational and Environmental Medicine. | National Alliance of Healthcare Purchaser Coalitions. (2021). purchaseralliance.org | Kaiser Family Foundation. (2023). kff.org | National Business Group on Health. (2022). businessgrouphealth.org | Employers Health Coalition. (2022). employershealthcoalition.org

Patient Demographics and Population Health Anderson, G.F. (2010). Johns Hopkins Bloomberg School of Public Health. | Tikkanen, R. & Abrams, M.K. (2020). Commonwealth Fund. commonwealthfund.org | Collins, S.R. et al. (2022). Commonwealth Fund. commonwealthfund.org | Bureau of Labor Statistics. (2023). bls.gov | Petterson, S. et al. (2012). Annals of Family Medicine.

Advanced Practice Clinicians and Nursing Laurant, M. et al. (2019). New England Journal of Medicine. | Naylor, M.D. & Kurtzman, E.T. (2010). Health Affairs. healthaffairs.org | National Academy of Medicine. (2021). nationalacademies.org | AAMC. (2021). aamc.org

Legal, Tax, and Compliance Eischen, J. (2025). eischenlawoffice.com | DLA Piper. (2025). dlapiper.com | IRS Notice 26-05. irs.gov | CMS. cms.gov

Organizational and Professional Identity Research Hoff, T.J. (2010). Practice Under Pressure. Rutgers University Press. | Scott, W.R. (2008). Institutions and Organizations. SAGE Publications. | Freidson, E. (2001). Professionalism: The Third Logic. University of Chicago Press. | Wolinsky, H. & Brune, T. (1994). The Serpent on the Staff. Putnam. | Gevitz, N. (2004). The DOs: Osteopathic Medicine in America. Johns Hopkins University Press. | Stephens, G.G. (1989). Journal of Family Practice. | Colwill, J.M. (1992). New England Journal of Medicine. | Bodenheimer, T. & Pham, H.H. (2010). Health Affairs. | Grumbach, K. & Grundy, P. (2010). JAMA.

Concierge Medicine Market Data Grand View Research. (2022). grandviewresearch.com | Precedence Research. (2023). globenewswire.com | MDVIP. (2020). mdvip.com | AAPP / Software Advice. (2023). softwareadvice.com

Disclaimer

The DocPreneur Leadership Podcast is produced by Concierge Medicine Today, LLC. This episode and summary are for educational and informational purposes only and do not constitute medical, legal, financial, or accounting advice. All factual claims are supported by named, verifiable third-party sources. Mention of any organization, publication, or individual does not constitute endorsement. Physicians and clinicians considering any practice model change are encouraged to seek qualified legal and financial counsel before making any practice or business decisions. © 2007–2026 Concierge Medicine Today, LLC. All rights reserved.