Patients sometimes tell me they are thinking about "one of those membership doctors" and then describe two quite different things in the same breath. Direct primary care and concierge medicine both charge a recurring fee for a closer relationship with a doctor, and both usually mean longer visits and easier access. Underneath, they work very differently, especially where insurance and Medicare are concerned.
Our practice offers a concierge membership, not direct primary care, so I have a stake in one of these models. I'll describe both as fairly as I can, using the definitions the American Academy of Family Physicians uses.
Two Membership Models That Are Easy to Confuse
The short version is that direct primary care replaces insurance for your primary care, while concierge medicine is usually layered on top of it. Everything else follows from that difference: what the fee covers, whether your Medicare or insurance is billed, and what you still need coverage for.
In practice, direct primary care tends to appeal to people who use primary care often and carry a high-deductible plan, since the membership makes routine visits predictable. Concierge medicine tends to appeal to people who want to keep their existing insurance or Medicare working as it does now while adding time and access with their doctor.
What Direct Primary Care Is
The American Academy of Family Physicians describes direct primary care as a model in which practices charge patients a monthly, quarterly or annual fee that covers all or most primary care services, such as extended visits, clinical services, some lab work, and care coordination. The defining feature is that direct primary care practices generally do not accept insurance or participate in government programs, and rely on the membership fees alone.
Because the fee is the whole business model, direct primary care practices tend to keep their panels small and their pricing simple. The AAFP notes that they often suggest patients carry a high-deductible, wrap-around insurance policy to cover emergencies and everything outside the primary care office.
What Concierge Medicine Is
Concierge medicine also charges a membership fee, but in the AAFP's comparison it is the model that may bill insurance for covered services. The fee pays for access: more time, more availability, and a smaller patient panel. The visits, tests and procedures that insurance or Medicare normally covers are still billed to your insurance or Medicare in the usual way. Our article on concierge versus traditional primary care covers how a concierge practice compares with a standard insurance-based office.
The Differences That Matter Most
Insurance and billing
In direct primary care, you pay the practice and the practice generally does not bill anyone else for your primary care. In concierge medicine, you typically pay the membership and your covered services are still billed to insurance or Medicare, with your usual copays and deductibles.
What the fee covers
Because a direct primary care fee replaces insurance billing for primary care, it tends to cover a broader set of in-office services. A concierge fee pays for the enhanced access itself, and your insurance continues to cover the medical services.
Medicare
This is where the two models diverge most for older adults. Since direct primary care practices generally do not participate in government programs, Medicare does not pay for the care you receive there, and you would still rely on Medicare for hospital care, specialists and everything else. Many concierge practices, by contrast, keep billing Medicare for covered services. Before joining either kind of practice, ask about the physician's Medicare enrollment status; our guide to whether Medicare covers concierge medicine explains what participating, non-participating and opted-out status mean for you. For how the rest of your Medicare coverage works outside any membership, Medicare's comparison of Original Medicare and Medicare Advantage is the place to start.
You Still Need Coverage for Everything Else
Neither model is health insurance. A membership covers your relationship with a primary care practice; it does not cover a hospital stay, an emergency room visit, a specialist, imaging, or most prescriptions. That matters most for people living with chronic conditions. Managing diabetes mellitus or congestive heart failure well involves specialists, imaging and hospital care at times, and those costs sit outside any membership. Whichever model you consider, keep coverage that protects you from the large bills.
If you are comparing options on cost alone, our guide to what a primary care visit costs without insurance is a useful starting point.
Questions to Ask Any Membership Practice
- Does the practice bill my insurance or Medicare for covered services, or not at all?
- What exactly does the fee include: visits, lab work, after-hours access, care coordination?
- What is the physician's Medicare enrollment status?
- How do I reach the doctor after hours, and how quickly?
- What happens when I need a specialist, imaging or a hospital?
- How many patients does the doctor care for, and how is the fee billed and canceled?
Whatever the model, what you are really paying for is a steady relationship with a doctor who knows you, which is why continuity of care is worth asking about directly.
Which Model Does Zimmer Medical Group Offer?
Zimmer Medical Group offers a concierge membership in St. Petersburg led by Dr. Michael A. Zimmer, a board-certified internist. Members keep and use their existing Medicare coverage for covered services, and the membership provides the enhanced access. We also offer traditional, insurance-based primary care for patients who don't want a membership. We don't operate a direct primary care practice. Membership pricing and availability are discussed by phone at (727) 820-7800, so you always hear current information.
