Retainer Business Models: Direct Primary Care and Concierge Medicine

November 27, 2019 0 Comments
Retainer Based Business Models

Fed up with the complexities involved in trying to work in the health insurance model of healthcare? You are not alone. With the state of healthcare in the US being what it is, provider burnout is a very real thing.

  • Paperwork
  • Coding
  • Over-scheduling
  • Patients coming and going because their provider networks keep changing

This isn’t what you got into medicine for. You got into medicine to help people, have long-term relationships with your patients, and make a good income.

Achieving Your Dream Is Still Possible with Direct Primary Care and Concierge Care

Others have already left the insurance-based model of care for something new. These pioneers are trailblazing the way via retainer models like Direct Pay Primary Care (DPC) and Concierge Care. It will take a leap and some hard work to transition into a healthcare model that supports it, but it is possible.

The DPC and Concierge footprint is still small, but there are enough pioneers out there that you can easily research how others have made the transition. Those embracing the retainer approach are finding it offers a welcome return to the medical practice of earlier times.

This Isn’t Just Nostalgia! Becoming a Conceige Doctor is Attainable

Running a profitable DPC or Concierge Care business is attainable. It’s possible to prioritize your patients. You can remove yourself from your worst insurance contracts and still thrive financially.

We know if you are already a practicing provider, you’ve got what it takes to start your own Concierge or DPC practice. And we want to help you get closer to your dream.

That’s why we have created this comprehensive guide that will help you:

Debunking Direct Primary Care Definition Myths

Let’s start by immediately debunking the myths that hover around retainer practices. They are out there. We know you’ve heard them.

Some of these myths may be the only thing stopping you from making a positive change in your practice. Others may be contributing to negative stories arising from providers opening new DPC practices.

Either way, a lot of what you’ve heard thrown around in casual conversation about retainer practices may simply not be true or may have simply arisen from false assumptions.

For instance:

  • Retainer practices are only for the wealthy. FALSE.
  • Direct practices do not accept insurance. FALSE.
  • If their provider has a direct practice, patients don’t need it. FALSE.
  • Retainer practices make lots of money quickly. FALSE.

Is the DPC or Concierge Model Right for You?

Have you been yearning for an earlier time where providers weren’t reliant on insurance and had direct payment agreements with their patients? You aren’t alone. In the Physicians Practice 2017 Great American Physician Survey, 63 percent of those surveyed stated that they would consider switching to the retainer model if circumstances were favorable.

How would you determine if the conditions were favorable?  Or maybe that it’s just time for a change? Ask yourself these questions:

  • Does it bother you that your nurses could be spending up to 40% of their time on paperwork for insurance companies?
  • Did you know that insurance payor contracts are less profitable than you think?
  • Would you like to feel as powerful as the insurance company when it comes to caring versus all those insurance rules and restrictions?
  • Do you prefer to make decisions exclusively for your patients’ well-being?
  • Would you prefer to have complete control over all the financials?
  • Do you want to save money and provide better care? And not have to work with insurance companies anymore?
  • Would you like to have:
    • More time to spend with patients?
    • Less paperwork?
    • Professional satisfaction?
    • Less interaction with payers?
  • Do you want a better work-life balance in your day-to-day?
  • Wouldn’t it be great to interact with fewer patients?
  • Wouldn’t you feel relieved if you had lower overhead costs and fewer staff?

The Direct Primary Care and Concierge Care models give you the ability to do all of this and more. If you answered “yes” to any or all of these questions, it may be time to make the transition.

Benefits of Making the Transition

Now let’s really dig into the benefits of transitioning to a DPC or concierge care practice.

Benefit #1: Predictability of revenue.

With a monthly or annual commitment from patients, overall income is predictable, and the flow of revenue is steady throughout the year.

This makes cash-flow easy to navigate. When you crunch the numbers, you will also find that you require fewer patients with the DPC or Concierge model than the insurance-based model.

Benefit #2: Patients come in for fewer pointless visits.

Many patient’s visits are to touch base about medication changes, for minor acute problems (URI’s, stomach bugs, etc.), requests for work/school paperwork, or other issues that can easily be handled remotely.

With the DPC or concierge model, you can give patients a variety of ways to access you and your staff that doesn’t require them coming in for an office visit.

Benefit #3: Alternative communication tools alleviate pressure on the staff.

Keep patients from having to wait forever on the automated phone line. Secure text messaging can be used effectively to answer many questions people have about smaller health problems.

Simple things like rashes and acute illnesses can be communicated easier by text. Follow-ups to ask how patients are doing via a quick message is convenient and makes the patient feel cared for.

Benefit #4: A decreased volume of unnecessary visits opens up the schedule.

Although it is counter-intuitive, there is no benefit in being fully booked. In fact, you will be rewarded for having a relatively open schedule at the start of the day. An open schedule also quells patient’s fears about not having access to their providers.

And appointments are no longer hard to get or too short. With an open schedule, patients easily get same-day appointments and the attention that they deserve.

Also, keep in mind that patients are paying you monthly so they can get access to your care, not necessarily for the care itself. Never fear, you will be paid just as much on a slow day as a busy one.

Benefit #5: Patients have longer appointments.

Longer appointments allow time to explain, educate, listen, consider, and connect. You can get the whole story from a patient and treat them accordingly rather than only being able to focus on one singular problem. This equals better care and happy patients.

Benefit #6: You are more likely to run on time.

With the DPC or concierge model, you are no longer tied to the office visit as the only profitable means to give care. Healthy patients are no less profitable for your business. In fact, they leave the schedule more open than do sick patients.

Benefit #7: The elimination of the need to interact with payers.

This benefit will not come into play for concierge practices that choose to accept insurance alongside direct payments. Still, for those who choose to let go of insurance, contracts will no longer have any ties to insurance companies.

Imagine all of the time and energy saved if you and your staff are not spending it on administrative functions like verifying documentation requirements or getting prior authorizations.

Not to mention that there will be less focus on dealing with electronic health records and desk work that often contribute to burnout.

Understanding the Retainer Model Fee Structure

To get a better understating of where these benefits are coming from, let’s take a quick look inside the fee structure of retainer models.

There are two main differences between a traditional practice and a retainer practice like DPC or concierge care:

  • In DPC, the provider is paid directly by patients, not insurance or other third-parties. In concierge care, the provider may be paid by patients as well as insurance, depending on how they structure their business model.
  • The patient doesn’t pay for office visits but pays a low monthly fee that runs $50 per month on average in DPC and Concierge. Concierge practices usually cost more with the patient paying a higher monthly fee than a DPC patient. They may even require a significant annual retainer that may run from $1,800 to $18,000.
  • Hybrid practice models charge a monthly fee in addition to traditional insurance billing. Legally a monthly payment can only be collected in addition to insurance billing if the monthly fees are for “uncovered services.” This practice provides the opportunity for significantly increased revenue, but it also increases the risk of double-billing for a single service. Double-billing has especially adverse repercussions if Medicare or Medicaid is the payer.

The Downside of DPC and Concierge Care

We would be remiss if we didn’t mention potential drawbacks. Here are eight things you may experience when you choose the DPC or concierge model.

  • Your income may be lower when you first start out.
  • You may feel isolated.
  • You may have fewer patients than you are used to.
  • Other non-retainer based practices may become overburdened.
  • You may have difficulty recruiting patients and building your patient base.
  • Insurers may not cover services.
  • Best practices in this model have not yet been identified.

Where the AMA Lands When It Comes to the Retainer Model for Care

If you are interested in starting a DPC or Concierge practice but are concerned about how this model of practice fits in with the AMA Code of Medical ethics, you do not need to worry.

The AMA supports a providers’ right to choose their practice setting and has not only offered an opinion but guidance on retainer practices.

Understanding the Differences Between DPC and Concierge Care

The basics behind how and why you would want to start a concierge or DPC practice are similar, but there are a few differences between the two models. In the article “Difference between concierge and direct care,” Rob Lamberts, MD makes a very clear distinction:

“By definition, direct care providers:

  1. Do not accept money from insurance;
  2. Rely mainly on a monthly fee of less than $100 per month;
  3. As a consequence of the above, they have larger panels, between 400 and 800 per provider; and
  4. Focus more on saving money than on offering premium services.

On the other hand, concierge practices:

  1. Often accept money from insurance;
  2. Charge a higher monthly payment in addition to the insurance collection;
  3. As a consequence of the above, they can have relatively small panels, between 200 and 300 patients total (sometimes less);
  4. Tend to focus on “premium” services, such as vascular scans, “executive” lab panels, extended office visits, and even going along with patients to specialist visits.”

To break it down even more concisely, the basic idea of the DPC is to avoid dealing with insurance. There is a spectrum of services offered in both camps, but the general idea of DPC is to avoid insurance, lower overhead, and keep costs down.

Concierge care focuses on providing value-added services that lie outside the bounds of what insurance covers. Concierge practices must be certain the extra fees that they charge do not duplicate the charges they are collecting from insurance. They need to keep a close eye on duplication Medicare charges as this is illegal.

Ironing Out the Details

Although making the switch from your current practice into a retainer model can be costly and tricky, it will be successful if you think strategically and put a plan in place.

If you have been toying with the idea of converting, a number of questions have likely arisen. Let’s take a look at a few of the most commonly asked questions asked by providers who are considering making the transition into DPC or Concierge Medicine.

How Does It Work?

Retainer medicine is based on membership.  Patients pay a monthly fee and are provided with 24-hour access to their provider, same-day appointments, visits that take as long as needed to last address their concerns, and a variety of other amenities.

You are at the center of your patient’s medical nexus. You are their trusted friend and their advocate in navigating the healthcare system.

In the event of an emergency or something that cannot be handled in your own practice, you closely monitor hospital care and often personally brief and debrief specialists on behalf of your patients.

What Can I Expect to Happen with My Practices Costs?

One of the things that probably brought you to considering a DPC or Concierge model is the complexities and costs involved with insurance.

A recent study found that providers spend approximately 15% of their total revenue on billing and collecting. This study included paying staff, billing in-house, using a medical billing company, et cetera.

One of the most attractive parts of the concierge model is that DPC and some concierge providers don’t have to bill and collect from insurance payers.

Because of this, a retainer practice spends very little time or money on the patient collections process. Most DPC and concierge practices use recurring credit card charges that automatically charge the patient every month, which significantly reduces billing expenses.

Providers are also able to charge a nominal amount to patients because the provider isn’t working under contractual rates. This allows the provider more flexibility in their fee structure and allows for better access for patients.

Not only do the costs go down for the provider, but patients often actually pay less out of their own pocket than they would be using insurance – particularly those patients who are on a high-deductible insurance plan.

In fact, the lower cost to collect combined with removing the insurance payer creates a situation in which concierge providers earn a higher income while patients have better access to care for less money.

Will I Only Be Working with Wealthy Patients to Make a Decent Salary?

No.  It is time for this myth to be busted. Subscription-based medicine models can be both affordable for a patient and bring in a great salary for the provider.

Let’s do some math. The national average of patients held by a provider is 2500. Let’s cut that number in half and base our calculations on 1250 patients.

Let us assume that each patient pays a nominal per-month fee of $59 for access to this provider. This would result in $885,000 per year in revenue.

Now let’s conservatively assume 50% in overhead. Keep in mind you’ve already cut out a large part of your overhead by cutting out billing and dealing with insurance companies.

A primary care provider would have a $442,500 salary – almost twice that of the average salary of a family practice provider in 2019.

As you can see, even a moderately-priced retainer practice can provide a healthy provider salary— and you will have fewer patients.

What Happens with my Medicare patients?

This is where it gets tricky. Providers can privately contract with Medicare patients to provide service, but Medicare requires that the provider opt-out of Medicare.

If you opt-out, you cannot return to Medicare for two years, and you are not allowed to bill Medicare for this time for any Medicare beneficiary.

How Do I Handle My Existing Insurance Contracts?

This depends on where you are at with your practice and how you stand financially. If you have the financial infrastructure in place to be able to drop all of your insurance contracts at one time, then you can. Most providers aren’t able to do this, so a slow and strategic conversion is recommended.

  1. Review the lower 25% of your contracts— the ones that are likely costing you money or are barely breaking even for you.
  2. Analyze your hourly overhead (both fixed and variable) to see what you are actually earning under contractual rates. Consider converting the patients on contracts that are not making a profit to retainer patients.
  3. Review the terms of your payer contracts. For contracts that don’t have stipulations regarding charging patients for non-covered services on a cash basis, install a pilot retainer program without canceling all of your contracts outright.

How Do I Successfully Convert My Existing Patients to the Concierge Model?

The long-accepted concept that healthcare is a given right that patients don’t have to pay for directly is quickly dying. Patients with high deductible plans are getting a large dose of this reality as they now have to pay out-of-pocket for things that used to be covered.

This will make your task easier, but you will still need to educate patients about what you are trying to do and why.  You will need to communicate with your patients clearly the added benefits of paying monthly fees directly to you for better access, same-day appointments, shorter waiting times, etc.

Set realistic expectations. Patients may not automatically convert to this model.  You may need to temporarily hire someone to contact your patients and consistently educate them about why the concierge model is better for both patient and provider.

And you will definitely need to adjust your marketing strategy to promote your new concierge practice to attract new patients as well as converting existing patients.

Does the Retainer Model Only Work for Primary Care?

No. Concierge medicine is possible in many specialties, particularly for those who treat patients with chronic conditions. Almost any specialty can benefit from the concierge model.

For example, endocrinologists for diabetic patients, urologists for erectile dysfunction, OB/GYN for pregnant women, etc. can offer a cash-based or monthly subscription models to patients.

What Changes Will I Need to Make to My Staff?

The retainer model requires a higher level of dedicated customer service for your patients. Unless this was already a priority in your practice, you will need to train your current staff or bring in some new blood who are already customer service gurus.

Here are a few basic customer service tenets that are expected in the DPC or concierge model:

  • Phone calls are answered. Staff will need to pick up the phone before calls reach a ‘phone tree’ or voicemail.
  • Your office should look and feel comfortable and professional. Front-office staff should dress in a professional and welcoming manner.
  • Remove clutter from the office. You must convey organization.
  • Patients should be greeted in a genuine, friendly way.
  • Take down the glass partition— there is no more division between staff and patients.
  • Find standardized methods to gather feedback from patients.
  • Back-office staff should follow-up with patients after appointments or changes in medications to see how they are feeling.

Concierge and DPC patients are going to expect same-day appointments, shorter waiting times, and better provider communication and accessibility. You can use technology to satisfy many of these expectations.

HIPAA compliant systems allow for telemedicine and patient interaction. Telemedicine visits are convenient for both you and the patient and can save your patient an unnecessary trip to the urgent care center.  For this, they will not only thank you— but will probably either directly or indirectly recommend you to a friend.

Convinced a DPC or Concierge Model Would Be the Perfect Fit for Your Practice?

Do your homework first. DPC Frontier has a great online resources page that can get you started.  Combine your online research with in-person interviews.

Talk with other providers who have walked the path before you. They will have special insights into what worked for them and what didn’t, and you can also ask them any unanswered questions.

Four Questions to Consider

  1. What are the best geographic locations for your practice? Urban and suburban practices tend to be most successful for DPC’s and Concierge care.  Although practices can thrive in rural areas, they can present more challenges.
  2. Planning on dispensing medicine directly to patients? Be aware that eleven states prohibit direct dispensation of medication to clients. If you plan on dispensing medicine directly,  check out this overview, your state’s webpage, or contact your state medical board.
  3. Do you want to run a “Pure” or “Hybrid” practice?  Are you planning to “Opt-Out” of Medicare? Opting out is a straightforward process that can be found on the Association of American Physicians & Surgeon’s “How to Opt-Out of Medicare” webpage.
  4. Do you want to be totally independent, join a network, or be employed by a DPC Or Concierge Practice?   Moonlighting part-time in a DPC onsite clinic could help you learn more about how you would like to run your own clinic.  You could even use the moonlighting income as a financial stabilizer until your own practice takes off.

How to Set the Monthly Fee

The “ideal” patient for a retainer-based practice is one that doesn’t use your services frequently but can see the value in paying a monthly fee. Any practice is much more likely to have frequent visits from a 70-year-old than a 30-year-old.

Because of this setting fees based on age (starting at a smaller rate per month for children and increasing incrementally by age to a maximum fee per month for seniors) is a standard fee model.

The key here is not setting your prices too high for the younger patients and seeking generally healthy people who need you on occasion.

Office Space

A good office space is essential unless you are creating a micro-practice. Do you want your office space to be located in a medical center, a strip mall in a struggling economic area, or perhaps a less conventional, more cozy space like an old house zoned for an office space?

Think about the clients you want to serve, what they would be attracted to, and what you are most comfortable with.


A staff that believes in what you are doing is your next essential. They will work harder, care more about the practice, and stick around longer.  Their commitment to your practice will attract and retain more patients, as well.

Communication Tools

The right communication tools are invaluable. Patients place a high value on access to staff. Most patients value security in communication over ease of use. Make sure you invest in the following:

  1. A good phone system like Ring Central is a complex, inexpensive VOIP Internet phone system.
  2. A strong messaging system like Twistle is a HIPAA-compliant “chat” system.
  3. A secure system for E-mails. Although not the preferred form of communication in this business, as long as patients sign a HIPAA waiver, it is technically acceptable to use e-mail for communications if a patient prefers this method.
  4. Billing systems will make or break you and your staff.  Choose a billing system that is easy for the staff to work with, intuitive for patients to navigate, and that integrates with EHR systems.

The Money Side

Draft an estimated budget for your practice and determine how much capital will be needed to start it. There are many ways to minimize the amount of start-up capital needed, such as purchasing used equipment from hospital surplus facilities.

You can also be creative with costs around buying or leasing your office space. Some DPC micro-practice concepts avoid using an office space completely.

Create your fee schedule using price transparency. Determine the cost of services provided within your practice (labs, medications, pathology, basic procedures) then decide whether you will pass these through to the patient via an itemized list.

For services outside of your practice like surgery centers, radiology groups, specialists, and hospitals in the community, it may be more difficult to provide price transparency to your clients as these businesses are not always transparent with their pricing.

You can, however, work with specialists providers in the community to establish a transparent cash price referral system for their services.

If they are not already aware, educate these specialists about the fact that even though they may continue to participate in Medicare, they are no longer barred from offering prices below the Medicare reimbursement amount to cash-paying patients.

The Legal Side

Draft your DPC patient-provider contract. This contract will reflect your practice preferences in alignment with state and federal law.

Familiarize yourself with your state’s insurance code so as not to violate state insurance law or have your practice end up being labeled a health maintenance organization.

Assemble HIPAA forms, Medicare Opted-Out Agreements, and any needed registrations. Look at  OSHA and CLIA rules.  If you run a “pure” DPC practice (not a hybrid) and have chosen to opt-out of Medicare, you may now be less concerned about the False Claims Act and Stark Laws.

Consult an attorney who is familiar with direct primary care to draft or review your legal documents. You can cut down on legal costs if you draft the items on your own and then run your proposal by a contract attorney.

Attorneys familiar with DPC practices are still a rare find since DPC is only beginning to experience exponential growth.


Start by deciding which (if not all) of these three groups you will market to:

Individual Patients
  • Word of mouth is still priceless. If people like you and your practice offer immediate value, they will tell their friends.
  • Paid advertising such as newspaper advertisements are not effective, but many DPC and concierge providers have had success with radio advertisements.
  • Facebook or other social media outlets provide an easy communication tool for patients and those interested in your You can also promote posts on FB that target the exact demographic that you are interested in.

Employers basically come in three sizes: small (less than 50 employees), midsize (50-150), or large (> 150), and their needs and tax implications will vary based on their size.

The conversation you will have with those that have less than 50 employees will be fairly simple. With mid-size or large companies, you will either need to have an understanding of it. Or bring a consultant with you that has an understanding of the concepts of stop loss or level-funded health plans.

Third-party Organizations

These organizations might include the following:

  • Insurance Carriers, Brokers, Third Party Administrators
  • Medicaid Managed Care Pilots Medicare Advantage Pilots

Third-party administrators and self-insurance brokers are usually happy to steer patients to your practice because the DPC model aligns so well with the price-sensitive plans that they offer.

Regardless of which of the three primary groups you are targeting, it is important to start your practice’s website. You can direct people there from any of these groups to learn more about you and your practice.

The transition into concierge medicine can be challenging, but you can’t beat the benefits.

  • Wouldn’t you love to get back to focusing on your patient/provider relationship while still making the same, or better, income?
  • Wouldn’t you like to provide better and more focused care for your patients?

The healthcare landscape is shifting under our feet every day.  For many providers, this can be frustrating— but others are taking it as an opportunity to look for new and more authentic ways of running their practices.

Right now, many providers are making the transition into the concierge medicine model. Perhaps you’ve even considered it yourself but aren’t ready or haven’t had the time to take the first step.

First steps don’t have to be big ones. Even just reading this article can be a solid first step toward your intention.

How EvexiPEL Can Help

Whether or not you decide to start your own Direct Pay Primary Care Practice, EvexiPEL is here to support you in whatever way we can. Perhaps you don’t feel that you’ve been able to connect with as many patients as you’d like.

Maybe you don’t feel yours have the right resources to provide them with life-changing approaches and treatments. Perhaps you feel like your practice is in a rut, or you are simply looking for further training and education.

Becoming a certified EvexiPEL provider can help you grow your practice, sharpen your skills, learn a world-class hormone treatment, and help more patients.

When you become a certified provider, you’re getting:

  • Access to leading resources like hands-on practice with real EvexiPEL patients
  • Training under some of the most renowned hormone specialists in the world
  • Lasting practice support from a Practice Development Specialist

We make sure all of the bases are covered, and we’ll lead you every step of the way, from training to marketing.

How Do You Get Started?

Fill out our online contact form. We will get back to you to explain more about the EvexiPEL method, how you can reach patients, and answer any questions you may have.

Then we’ll send a Practice Development Specialist to learn about your history and your future goals, all while guiding you through comprehensive training.

Finally, you can focus on delivering quality service to your patients while we focus on providing you with long-term support and resources to enable your success!

Additional Resources

Resources that will further your education on the retainer model:

Article Name
Retainer Business Models: Direct Primary Care and Concierge Medicine
Whether or not you decide to use Retainer Based Business Models, EvexiPEL is here to support you in whatever way we can.