Illustration by Hannah Agosta

The post on Nextdoor resonated with Heidi Sheppard, mirroring the plight she and her family were facing.

Can anyone recommend a good family doctor in the area, or tell me your experience with SignatureMD? … Potomac Physician Associates will be closed this July and replaced by SignatureMD, which I understand that you have to pay an annual fee of $1500-2000 to join for what they call a “personalized care.” I don’t know if it’s worth it to do that since we are already paying close to $20K/year for our medical insurance right now.

The post was among a number of similar queries that cropped up last spring in local social media groups. They followed the announcement by Potomac Physician Associates (PPA), one of the area’s largest independent primary care practices, that it would be closing and that many of its doctors would be joining new practices affiliated with One Medical, MDVIP or SignatureMD.

“We are also in the same situation since we have used the doctors at PPA for years,” Sheppard replied. “I find this trend extremely disturbing as it is moving us even further away from a universal health care system and towards better medical care for those who can afford it.”

Sheppard had only recently started seeing a physician at Potomac Physician Associates, but her husband and two adult children had been seeing doctors at the practice for many years. Sheppard says she was contacted by phone, via email and through the mail to explain the transition and the benefits of a concierge model. PPA physicians even held webinars to talk up concierge care, in which patients pay a retainer to their physician for care that typically includes longer appointments and the ability to contact your doctor by phone or email nearly 24/7. Still, she and her family opted out.

“I understand doctors are having a hard time, too, and our medical system is awful; but we can’t afford that,” says Sheppard, 61, who lives in Kensington.

“We’re already paying a gazillion dollars for insurance. …Why would I spend $1,300 just so the doctor will call me back? They should be doing that anyway.”

Sheppard had no trouble finding a doctor who was taking new patients, wasn’t charging extra for a boutique practice and was an “in-network” provider with her insurance. She based her decisions on conversations with friends, online reviews and an initial virtual appointment with her new doctor. She believes she found someone she can trust, but is still disappointed that she had to switch doctors for the second time in just a couple of years.

Three years ago, Richard Ireland faced a similar choice: pay $1,800 a year to stick with the doctor he had been seeing for two decades or find a new one. His longtime primary care physician, Collin Cullen, was leaving the traditional practice he ran with his brothers to launch one that promised more personalized care and access in return for an annual fee.

Ireland chose to stay with Cullen, a decision that reflected his comfort and relationship with the physician as much as any desire to see a “concierge” doctor. In fact, he chose Cullen more than 20 years ago partly because it was early in the physician’s career. Ireland assumed that meant he could build a relationship that would last well past his own retirement from his job as an engineer with the Navy.

“Initially, I was taken aback,” by Cullen’s announcement in 2019 that he was changing to a membership model, “and I was questioning whether I would do it or not,” says Ireland, 72, who lives in Chevy Chase. “I’ve had quite a few health issues…he’s very familiar with what my issues are and very comfortable talking about them.”

The fee buys Ireland a comprehensive annual exam that he calls “very thorough—the information he passes on to me is about double what I used to get.” Ireland also appreciates that he can call in the morning and get an appointment with Cullen later the same day if he needs one. Even Cullen’s office staff, Ireland says, is more attentive and responsive than before the doctor’s switch to a concierge practice, likely because concierge physicians see significantly fewer patients than most other primary care doctors.

“I also get updates from him—he takes the time to respond to my email directly,” Ireland says. “In the previous arrangement…email was never answered…now the communication is a lot more direct and prompt.”

The exact number of physicians practicing in these models is unknown, but it is clearly rising, not just in the Washington, D.C., area, but across the country. According to a report published by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, a 2019 survey of nearly 2,000 Americans found that more than one in five adults with a household income of more than $500,000 participate in some type of concierge medicine.

In the case of the doctors formerly associated with PPA, those in the practice’s Chevy Chase office transitioned to One Medical, a nationwide company that promises 24/7 access to on-demand virtual care and same-day or next-day appointments for an annual fee of $199. Seven physicians remained in PPA’s former office on Fernwood Road in Bethesda; they opened Bethesda Internal Medicine Partners, a practice aligned with SignatureMD, which operates under a more typical concierge model with a larger annual fee of about $1,800.

The former PPA did not make anyone available to respond to questions from Bethesda Magazine.

Interviews with several local doctors and patients confirmed that these shifts in the primary care landscape are part of a trend: Fewer traditional insurance-based independent practices exist, with more primary care doctors either joining large hospital systems, such as MedStar or Johns Hopkins, or—like the former providers at Potomac Physician Associates—opting for a membership-based model. The trend has raised concerns that a shortage of primary care physicians is only being exacerbated, and also has left some patients confused or questioning what they’re paying for.

It doesn’t help that no two practices look quite the same, with an evolving terminology not even agreed upon by the physicians and certainly not yet understood by most of the public. For example, a “concierge” model typically comes with an annual contract, and services can still be billed “in-network” to insurers with whom those doctors have a contract.

But there’s also “direct primary care,” which typically has a lower fee and doesn’t bill insurance as an in-network provider. A 2018 survey of direct primary care practices by the American Academy of Family Physicians found that the majority of responding doctors charged individuals $50 to $75 per month to be members of the practice. The vast majority of those surveyed—87%—said they did not charge any additional fees per visit.

And then there’s everything in between—models like One Medical, with a relatively low annual fee but still in-network with many insurance plans. What each of these models has in common is that the physicians who practice within them argue that traditional insurance-based primary care practices aren’t providing what many patients need.

“The problem is not the doctors, though. It’s the system,” says Matthew Mintz, an internist with a concierge practice in North Bethesda. With a traditional system, “it’s volume-based care, which means it’s hard to get an appointment, it’s impossible to see your doctor when you’re sick. …The doctor’s staring at the computer screen half the time; they have to click, click, click the electronic record. [Despite] the high premiums everyone pays, that’s what your insurance gives you these days: high-volume, bulk primary care.”

Defenders of concierge or direct primary care practices say they’re not for the super rich or hypochondriacs, but simply for people who feel that a special relationship with a primary care physician is worth paying for. In many cases, the patients tend to be older or suffering from chronic conditions, meaning they spend more time navigating the health care system. Others simply appreciate the time they get with the doctor—often an hour for an annual physical and 30 minutes or more for other visits. They relish the opportunity to sit down in an office and ask questions. Mintz says it’s the same factor that motivated him to start his practice.

“A primary care physician, in my opinion, that practices in Bethesda, Chevy Chase or Rockville should be able to make a salary that supports a family that lives in that area, and currently what primary care physicians are paid does not do that,” Mintz says. But he doesn’t think compensation is driving doctors to other models; it’s the limitations of insurance-based practices. “These doctors are not delivering the kind of care that they want to deliver. The patients don’t have access to them, so they’re not doing the thing that got them into medicine in the first place.”

Hi! Does anyone here currently see a doctor (for yourself) at Potomac Physicians [sic] Associates (Bethesda/Fernwood location)? I’m reading over the info about how the doctors there are starting this new personalized practice and I’m a bit confused… Have any other patients made any sense of the options – besides paying to become a member? It seems all other locations are closing?

“Same!” Jamie Kramer replied to the Facebook post. “They are going boutique which has become common in recent years. I don’t see the benefit unless you have a lot of ‘stuff’ or have a strong need to be able to text or call your doctor 24 hours a day. It’s more common for people 60+ for example to see a concierge doctor as they are aging.”

Kramer, 35, wasn’t completely surprised by the announcement. She had heard rumors that the practice might be switching to a membership or concierge model. It didn’t take the North Bethesda resident long to decide that she would have to find a new primary care practice. She quickly made an appointment to see her Potomac Physician Associates doctor one last time in July, just weeks before the practice closed and reopened under the SignatureMD banner.

“I feel very fortunate…that I’m healthy, and I’m young,” says Kramer, who owns a local event planning company. “For me, it’s not something that feels absolutely necessary to do. …There are plenty of great doctors in the area; it doesn’t feel necessary to pay that amount. I feel like it makes a lot more sense for my parents’ generation.”

Kramer hasn’t found another doctor yet—she doesn’t feel a rush since she sneaked in that last physical with her previous doctor—but isn’t worried about it. Like many people her age, she is less concerned about being able to see the same physician every time she has a medical question, taking into equal consideration factors like convenience, location and cost.

Although Dr. Tim Arling’s office is in the same building that used to be home to Potomac Physician Associates’ Chevy Chase practice, it wasn’t an elevator conversation or an online neighborhood discussion that alerted him to the news that his fellow primary care providers were shifting to a membership model. In fact, every time a primary care practice makes a similar move—and it’s happened several times in the last few years—Arling usually knows within days.

“Suddenly there’s a dramatic surge of patients of one doctor trying to call around to local doctors to see if they’re accepting new patients,” he says. This time was no different; Arling, who has been with Capitol Medical Group since helping launch its adult internal medicine practice in 2017, has added new patients who previously saw PPA physicians. Some of them don’t feel the need for a concierge practice because they are relatively healthy, he says, while others simply can’t afford it. A third group is just annoyed and thinks the doctors are simply trying to get rich, Arling says.

“I never have them say, ‘Well, I wonder why [the doctors] feel like they needed to do that; I wonder what changed…did something happen in terms of their reimbursement such that the model was no longer as economically feasible’ or anything,” he says. “It unfortunately kind of paints doctors in a bad light, but I don’t think anyone goes into primary care because they think that’s going to be their easiest way to make a ton of money.”

Judith McGuire isn’t entirely unsympathetic to physicians—she also accuses insurance companies of being at the root of the problem—but she doesn’t buy into the idea that concierge medicine is a better model. When Lisa Kaufman, her former primary doctor with an office in downtown Washington, announced that she was changing her model, McGuire didn’t hesitate to find someone new.

“I wasn’t surprised, but I was disappointed,” says McGuire, 71, who lives in Chevy Chase. “I think they said it was going to be 1,800 bucks per year to belong, and that just didn’t make sense to me.”

Kaufman’s practice, Dupont Private Health, says the membership comes with many benefits: same-day or next-day appointments, 24/7 access to your physician via secure messaging, comprehensive wellness coaching and more. But McGuire, expressing sentiments shared by others, thinks that most people who pay the annual fee are “wealthy elitists [or] wealthy hypochondriacs” who “can have someone they can order around.”

McGuire didn’t take finding a new doctor lightly: Earlier this year she shared on a Chevy Chase group email list a spreadsheet of primary care physicians that she had created during her search. She says it wasn’t easy to find one who was taking new patients. In the end, she says, even her new doctor wasn’t supposed to be accepting new patients, but her staff scheduled the appointment anyway. The doctor, part of a practice in the Johns Hopkins system, agreed to keep seeing her.

“I lucked out,” says McGuire, who worries about others who might be having trouble finding a physician.

Mintz fears this will be the experience of more and more people in the D.C. area. As physicians go concierge, they will decrease the number of patients they are willing to see. Many patients will either choose or be forced to seek out the shrinking but still significant number of primary care doctors who qualify as in-network providers by insurance and don’t charge an annual fee.

Arling, though, continues to take on more patients, and he has been able to hire an additional physician and a nurse practitioner. Many patients, meanwhile, are perfectly happy in systems such as Kaiser Permanente or One Medical, which may not give you immediate access to your personal physician but do provide around-the-clock telehealth or urgent care appointments. McGuire, for example, isn’t concerned that she might not speak to her doctor right away when something comes up suddenly.

“I feel like at Hopkins there’s a lot of other resources,” she says. “You can send an email, and you can get a callback.”

For some, a call from a nurse or an unfamiliar doctor doesn’t match their expectations of a primary care physician. Some even say that concierge or direct primary care medicine reminds them of the health care of their childhoods. Frank Filderman, 62, grew up in the Washington area and remembers a doctor coming to the house when he or one of his sisters was sick. Filderman’s physician, Mintz, doesn’t make house calls, but Filderman, a resident of Bethesda, appreciates the time he gets when he visits the office.

“What outweighs [only] having to pay a $30 copay is the ability to see somebody pretty much on demand, if you will…and not having to wait,” Filderman says. “He absolutely understands you, takes copious notes when you’re meeting with him.” While previous doctors had to “open up the computer just to get caught up on who I am,” Filderman feels Mintz knows him well enough now to provide personalized care. That’s something Filderman particularly values while recalling an experience in which he was misdiagnosed and referred to urgent care and a cardiologist by a physician he didn’t know—all for what he says turned out to be an allergic reaction.

“When I meet with [Mintz], if something comes up with my heart, with my back, [or] for whatever reason, where he’ll point me [to] is somebody he knows will take care of me,” Filderman says. “Because he knows what my needs are.”

Michael S. Gerber is a writer and consultant in Washington, D.C.