I have practiced medicine in enough different settings to be pretty convinced there is no perfect practice model.
What changes from one model to another is not just how the physician is paid. It is how much control the physician has over the patient experience.
In a large employed or academic system, the physician may have extraordinary resources around them, but much of the experience is designed by the institution: centralized scheduling, call centers, referral systems, portals, staffing rules, visit lengths and access policies. The individual doctor may be excellent and still have relatively little control over what happens before or after the patient is sitting in front of them.
Solo practice is very different. The physician can decide how the phone is answered, who patients communicate with, how quickly they can get in, how long visits last, how follow-up works and what the office feels like. It can be an unusually personal way to practice medicine.
The limitation is economic. A solo in-network physician usually has far less negotiating power with insurance companies than a large health system. The physician accepts contracted reimbursement, carries the overhead and still has to make the numbers work. Often that means higher volume, which limits how fully that personalized model can actually be carried out.
Concierge and out-of-network practices don’t necessarily create a different philosophy of care. They change the economics enough to make it possible to execute that philosophy more fully. Lower volume, longer visits, easier access, direct communication and more time spent coordinating or following up all become much easier to build into the practice when reimbursement better reflects the time and service being provided.
That doesn’t make one model inherently better. Each solves a different problem and creates a different tradeoff.
When I was deciding how I wanted to practice, I found it useful to map them from both sides.
From the patient’s perspective
| Practice model | Affordability | Continuity | Personal / direct access | Time & attention | Complex-care fit |
|---|---|---|---|---|---|
| Academic medicine | M | L–M | L–M | M | H |
| Large employed group | H | M | L–M | L–M | M |
| Community / system clinic | H | L–M | L | L | M |
| Solo in-network | H | H | M | M | M–H |
| Solo in-network + admin fee | H | H | M–H | M–H | M–H |
| Private out-of-network | M | H | H | H | H |
| Concierge / membership | L | H | H | H | M |
From the physician’s perspective
| Practice model | Autonomy | Control of patient experience | Work-life control | Administrative burden* | Economic control |
|---|---|---|---|---|---|
| Academic medicine | L | L | L–M | H | L |
| Large employed group | L | L | M | M–H | L |
| Community / system clinic | L | L | M | H | L |
| Solo in-network | H | H | L | H | M |
| Solo in-network + admin fee | H | H | L–M | H | M |
| Private out-of-network | H | H | H | L–M | H |
| Concierge / membership | H | H | H | L–M | H |
H = high/favorable · M = moderate/mixed · L = low/unfavorable
For administrative burden, H means more burden.
These are broad generalizations. Individual practices can look very different.
But the tradeoffs are real.
Large systems provide infrastructure, scale and resources, while much of the patient experience becomes standardized by the institution. Solo practice gives the physician tremendous ability to personalize care, but insurance reimbursement can limit how much time and service can realistically be built around each patient. Concierge and out-of-network models preserve that same physician control while improving the economics enough to reduce volume and optimize the experience much more fully.
The question isn’t which model is best. It is what each model makes possible, what it makes harder, and whether those tradeoffs match what the patient and physician are looking for.
