Sara Headley was regularly putting in 50-hour weeks to see as many as 20 patients a day when she worked as a family nurse practitioner for Community Health Centers of Burlington. Despite maintaining a nonstop schedule that was hard to balance with raising a family, Headley said she still did not feel like she was giving her patients the care they deserved.
“I didn't really have much time to talk to them about deeper concepts of health and prevention,” she said.
And so, like many of her peers struggling to make it work in primary care, Headley quit. She opened her own practice, Mint Health, in Waterbury last year. There, Headley charges patients a monthly membership fee, in addition to billing insurance. In exchange, she promises shorter wait times and more individualized care.
It’s a model known as concierge medicine, and the number of Vermont health care providers shifting to this type of practice is growing fast. But while such practices offer respite from burnout for providers and a more personalized experience for patients who can pay, they also raise vexing questions about those who are left behind.
“In the short run, this does exacerbate the primary care workforce crisis and the access crisis,” said Zirui Song, a physician economist at Harvard Medical School who has studied the exponential growth, nationally, in membership-based primary care medicine.
A study Song co-authored late last year tracked the rise in concierge medicine and direct primary care, a similar model that typically uses fees to cover the cost of services and bypass insurance. It found that the number of clinicians charging such fees — which can range from a few hundred to tens of thousands of dollars a year — grew by nearly 80% between 2018 and 2023.
"It’s a response to a broken market."Susan Ridzon, executive director, HealthFirst
Vermont’s experience appears to be tracking national trends. About 20% of all practices that belong to HealthFirst, the organization that represents the state’s independent doctors, now operate concierge or direct primary care practices.
“It’s a response to a broken market. I mean, these clinicians, they value that relationship that they have with their patients. And this is a way to get back to that,” said HealthFirst Director Susan Ridzon.
The U.S. — and Vermont — suffers from a well-documented shortage of primary care providers.
The Vermont Medical Society says the state is currently short about 100 primary care doctors, and that this shortage is expected to get worse as providers retire and aren’t replaced. For patients trying to find a medical home, wait times are long.
Reimbursement rates are a major factor, as clinicians generally get paid less for primary care than for specialty services. Those that choose to enter or remain in the field often have to pack their schedules with patients in order to keep the lights on at their practices.
Enter the concierge solution. Supplementing their revenues with membership fees allows clinicians to substantially reduce the number of patients they see — and provide those willing and able to pay with far more attentive care.
But people who can’t afford added fees are often those most likely to need extra care.
“They are our most vulnerable patients,” said Stephanie Winters, the deputy executive director of the Vermont Medical Society.
Provider groups say that the rise in concierge medicine is what happens in the absence of a system-wide fix, and have lobbied hard this year for payment reform.
“The goal is to create a system that allows for everyone to receive that type of personalized care,” Winters said.
Headley with Mint Health credits the concierge model with allowing her to stay in primary care. But she’s also struggled with the concept, and attempted to keep fees as low as possible. Her individual plans cost between $20 and $90 a month — far less than what many of her competitors charge.
Mint Health patients who spoke to Vermont Public say the extra attention they’re getting is well worth the added fee.
Michael Frank remembers a time growing up when everyone knew his name when he walked into his doctor’s office in Waterbury. He said he signed up for Mint in the hopes of getting “back to what medicine used to be.”
So far, Frank raves about the experience, and the emphasis Headley has put on preventative care. He said in an interview he planned to head Mint later that afternoon so they could discuss his exercise plan. His wife, Melody, was similarly effusive.
“They are looking at big picture and thinking about what's going to make you your best self, both today and like, moving forward,” she said.
It’s not just doctors and patients who are drawn to this model: so are investment firms, who see opportunities for reliable returns. MDVIP, a private equity-owned company that operates the largest network of concierge physicians in the country, now counts six doctors in Vermont. Half joined within the last year.
Doctors have increasingly welcomed this interest from the private market. Song, the Harvard researcher, found a nearly six-fold increase in corporate-affiliated membership-based primary care practices within the five-year period he studied.
“That is striking,” he said, given that so many clinicians say they’re going the concierge route “because they were motivated to retain their autonomy.”
Lorissa Segal, an internal medicine doctor in Woodstock, is MDVIP’s newest doctor in Vermont. She said she liked MDVIP’s “preventative focus” and the comprehensive labs they offered as part of their membership, which costs between $2,000 and $3,000 a year.
"Especially in primary care, we're really interested in caring for the whole person, and that takes time to do."Lorissa Segal, internal medicine doctor, Woodstock
Leaving Mt. Ascutney Hospital, where she had worked for the last 17 years, and going the concierge route will allow her to cut her patient panel down by more than half, she said. The time she’s getting back will allow her to offer same-day or next-day appointments, and call patients herself when lab results come back. Recently, she said, she’d even done a home visit.
“Especially in primary care, we're really interested in caring for the whole person, and that takes time to do,” she said.
But she admits there’s a downside, too. Hundreds of her former patients now have to look elsewhere for their primary care.
“These are people who I've been taking care of for 15 years or more. So I know them, and I know their families and extended families,” she said. “To leave a lot of them behind is really difficult.”
Song’s research indicates that the greatest number of physicians who go into membership-based practices are, like Segal, fleeing hospital systems. But others come from a wide range of settings, including independent practices and federally qualified health centers, like Community Health Centers of Burlington.
Michelle Dorwart, a family physician at the center’s Riverside location, has witnessed the trend firsthand. She’s observed at least three colleagues leave since 2023 for direct primary care or concierge practices.
She doesn’t begrudge her colleagues, and admits to flirting with the idea from time to time. But a significant number of her patients rely on public insurance and have low incomes. And while she likes the idea of spending more time with patients, too many of the people she cares for couldn’t afford the extra fee.
“I totally get why physicians would take that route,” she said. “I can't figure out a way to sort of see how we can take care of the whole community if everyone were to do that.”
