November 21, 2025
Dear Interested Readers,
Thoughts While Visiting Portland, Oregon
Early last Monday, my wife and I were up before dawn in order to get to the airport in Manchester with plenty of time to make it through any unexpected barriers at TSA that might persist after the government shutdown. To our delight, there were no delays. Indeed, the airport felt empty. Flying from Manchester to the West Coast always requires at least one plane change, and each transfer is an opportunity for a travel delay. For this trip, we changed planes in Baltimore and Denver. To our delight, all of our flights arrived early and departed on time. Nevertheless, from our door to our touchdown in Portland was 15 hours. It was a long day, but it could have been worse.
We came to Portland to visit old friends, Doug and Leslie Beers. I first got to know Doug when Harvard Community Health Plan hired him in 1981 after he completed his residency in medicine at the Brigham. Over a very short time, our relationship clicked. Our wives became friends, and each family had a child in 1982. We spent many happy weekends together before 1984, when Doug suddenly announced that they were leaving Boston. He had taken a teaching position at Emanuel Hospital in Portland. Emanuel is a Level 1 trauma center and safety-net hospital in the heart of Portland that, after several mergers, is now part of the extensive Legacy Health network, which includes six hospitals, a children’s hospital, and 70 clinics in metropolitan Portland and Vancouver, Washington.
Doug was the subject of a couple of my letters back in 2015, which explained his abrupt exit from Boston after a systems failure left him feeling morally injured. Over the years, we have maintained a close relationship, even though at times it has been as much as seven years between our visits to Portland or his returns to the East Coast. One of our sons attended Reed College between 2001 and 2005, during which we had many visits to Portland. Over the past fifteen years or so, we have enjoyed visits to see Doug and Leslie both in Portland and at their beach home in Manzanita, built mostly by Doug with help from Leslie. Besides being the best practicing physician with the greatest fund of knowledge of any doctor I have ever known, Doug is a master craftsman, has a degree in Marine biology, is a multi-instrumentalist, has sung opera in Vienna, is trilingual, and is an avid backpacker. He rides his bicycle eight miles each way to and from his office most days of the year. When he was in Boston, he would ride twenty-seven miles to the office in Kenmore Square each way from a home he remodeled and expanded in Sudbury. He scored a perfect 1600 on the College Board before attending Stanford for his BS and UCSF for medical school. The degree in marine biology was a detour to the University of Washington between Stanford and UCSF. Doug is a Renaissance man.
Whenever we are together, I usually come away from the visit with a few new book titles to check out. What I know about Doug, I have learned one fact at a time through many conversations over forty-four years. He doesn’t spontaneously talk about himself, nor does he regale you with his accomplishments. Fortunately for me, I have learned how to ask the questions that open him up. He also asks questions and makes well-considered suggestions. Patients, interns, and residents love him, and though he is 75 and has cut back to four long days a week in the office (about 10-12 hours), retirement is not something that interests him.
Doug was an early clinical authority on the management of HIV and Hepatitis. His interest began in 1981 as we were seeing our first patients with strange symptoms that baffled us, like lumps that turned out to be Kaposi’s Sarcoma, which was soon discovered to be common in AIDS. My first patient with HIV had seen me for over five years for routine care when he presented with a strange lump. We were surprised when the biopsy pathology came back as Kaposi’s sarcoma. In those early, confusing days of HIV, Doug quickly developed an interest in managing patients with HIV infections and has been doing it with great skill for over forty years.
Over the years, Doug has had hundreds of patients with HIV, and until the mid-nineties, most of them died. He relates that in the mid-nineties, the protease inhibitors arrived, and his patients began to survive their HIV disease. Most of his HIV patients who have died since the mid-nineties have died of other medical issues or events like trauma. Multidrug approaches, including integrase inhibitors, were initiated around 2007 and provided even better management options. Because of the evolution of effective therapies, there have been very few deaths from HIV in Doug’s practice over the last 25 years.
What disturbs him is that the majority of his patients who have died over the previous twenty-five years have been black women. He asks himself why. Is it his failure as an older white man from a different culture to form effective therapeutic relationships with these women who are different from him in almost every biological and cultural way? At this point in our conversation, Leslie, Doug’s wife, a visiting nurse who knows the community from her decades of going into the homes of many of these women, says that the problem is not him or any implicit bias he might have. The problems that make it difficult for these women to be compliant with therapy and contribute to their deaths are the social problems in the community that fall heavily on these women and are beyond his reach from his office at the hospital. Even if he is blameless, I could tell that it did not make Doug feel better. We are back to the same “moral injury” reality that faces so many dedicated and well-meaning providers of care who see patients suffer and are distressed when they are unable to give their patients what they need, for reasons far beyond their individual ability to provide.
In another conversation with Doug, as I was asking him about his practice and his teaching experience with interns and residents, I asked him if many of them were going into primary care. His answer was “Not many.” He thinks that most see themselves as future hospitalist, intensivists, or in some interventional specialty. When I asked what he thought about the future of primary care and whether it would survive, he frowned and, with his body language, gave an answer I interpreted as “Who knows?”
I then asked him what he thought of concierge care. Another scowl appeared. I can’t remember his exact words, but in essence, he said, “It’s an abomination. It does not solve the problems of primary care. It creates at least two tiers of care, removes clinicians needed for equitable care for everyone, and further complicates the professional lives of physicians and nurses who are trying hard to provide quality care to the larger population of those who can’t afford the extra expense.
I totally agreed. My analogy is that concierge care mirrors the extraction of funds from public schools through the creation of vouchers that allow those with means to take advantage of private schools, leaving children who can’t use vouchers to access private education and leaves other children with larger classes, older, dated facilities, and overworked, stressed-out teachers. I see concierge medicine as creating even more inequity in healthcare. It is a solution for the privileged few.
Some weeks ago I had asked ChatGPT, “What are the pros and cons of “concierge medical care?”
ChatGPT said:
That’s an excellent and timely question — especially as primary care faces workforce shortages, burnout, and growing frustration among both patients and clinicians.
“Concierge medicine,” also known as direct primary care (DPC) or retainer-based medicine, represents one of the most significant experiments in U.S. healthcare delivery over the past two decades.
Let’s break down what it is, how it works, and the key advantages and disadvantages — for patients, physicians, and the healthcare system at large.
🩺 What Is Concierge or Direct Primary Care?
Concierge medicine is a membership-based model in which patients pay a monthly or annual fee (ranging from about $80–$250/month, or $1,000–$3,000/year) for enhanced access to their primary care physician.
Depending on the practice, this may or may not bill insurance for visits —
- Concierge Medicine: often bills insurance in addition to the membership fee.
- Direct Primary Care (DPC): typically operates outside of insurance entirely, relying solely on membership fees.
In both cases, the goal is to shrink patient panels (from 2,000–3,000 down to 400–800 patients per physician), allowing more time per patient, longer visits, and personalized, continuous care.
✅ Pros of Concierge Medicine
1. More Time with Patients
- Appointments typically last 30–60 minutes, compared to 10–15 in traditional fee-for-service (FFS) primary care.
- Allows for deeper understanding of patient history, mental health, social determinants, and prevention.
2. Better Continuity and Access
- Same-day or next-day appointments are standard.
- Physicians are available by text, phone, or email—reducing urgent care or ER visits.
- Continuity fosters stronger physician-patient relationships and higher satisfaction.
3. Reduced Administrative Burden
- Fewer insurance claims = less time spent on paperwork, coding, and prior authorizations.
- Physicians can focus on clinical judgment instead of documentation for billing.
4. Prevention and Lifestyle Focus
- Concierge physicians can spend more time on nutrition, exercise, and early detection, improving long-term outcomes.
- Patients often undergo more consistent preventive care, screenings, and follow-up.
5. Improved Physician Satisfaction
- Smaller patient panels and reduced bureaucracy dramatically lower burnout rates.
- Greater autonomy in scheduling, clinical decision-making, and patient selection.
6. Potentially Lower Overall Costs (for certain patients)
- For patients with multiple chronic conditions or frequent primary care needs, reduced ER and hospital use can offset membership fees.
- May reduce unnecessary specialist referrals and tests.
That sounds terrific. It would appear to be the answer for frustrated patients and burned-out clinicians alike. What’s the problem? There are many problems, not the least of which is that this service is only possible for a tiny number of the total patient population, and it sucks resources from critically underserved populations. The Chatbot explains the problem in great detail.
⚠️ Cons of Concierge Medicine
1. Access and Equity Concerns
- Membership fees exclude lower-income patients and those without disposable income.
- As more physicians shift to concierge models, access to primary care for the general population shrinks — worsening national shortages.
- This can lead to a two-tiered healthcare system: personalized care for the wealthy, crowded clinics for everyone else.
2. Potential for Widening Disparities
- Particularly harmful in rural or underserved urban areas where physician supply is already thin.
- May draw doctors away from community health centers and Medicaid patients.
3. Limited Network and Insurance Coordination
- DPC practices that don’t take insurance may leave patients without help navigating referrals, hospitalizations, or specialty care.
- Patients still need insurance for hospitalization, surgery, and specialty visits — which can be confusing.
4. Ethical and System-Level Concerns
- Critics argue that concierge medicine prioritizes profit over population health.
- By reducing physician panels, it effectively decreases system-wide capacity.
- Public health advocates worry that this undermines efforts to build equitable, community-based care models.
5. Variable Quality
- The concierge label isn’t standardized — quality can vary widely.
- Some practices focus on true primary care; others market themselves as “executive health” boutiques emphasizing convenience over comprehensive care.
6. Regulatory and Continuity Risks
- If a concierge practice dissolves or the physician retires, patients can suddenly lose care continuity.
- Few states regulate or license concierge medicine models directly.
🧭 Policy Implications and Emerging Trends
- Growth: As of 2024, estimates suggest 4,000–5,000 concierge or DPC practices across the U.S., serving around 1.5–2 million patients.
- Trends:
- Increasing corporate investment (e.g., One Medical, Forward, Amazon Care) blurs the line between boutique and mainstream primary care.
- Employers and Medicare Advantage plans are beginning to experiment with hybrid DPC models for populations with chronic disease.
- Policy Discussions: Some advocates propose subsidizing “concierge-lite” DPC practices in rural or underserved areas to attract providers while maintaining affordability.
🩹 Summary Table
| Aspect | Advantages | Disadvantages |
| Access | Fast, easy, direct access to your doctor | Expensive; limited to wealthier populations |
| Quality of Care | Longer visits, preventive focus, better communication | Unequal distribution of care resources |
| Physician Experience | Less burnout, more autonomy, stronger relationships | May leave fewer providers for the general population |
| System-Level Impact | Potentially more efficient for enrolled patients | May worsen national access and equity gaps |
| Cost to Patient | Predictable monthly/annual fee; fewer hidden costs | Upfront cost not feasible for many |
| Integration with Insurance | Often includes insurance billing (concierge) | DPC models can complicate referrals and coverage |
💡 Bottom Line
Concierge medicine can dramatically improve the experience of both doctors and patients — but only for those who can afford it.
Its expansion raises critical questions about equity, fair distribution of healthcare resources, and the social contract of medicine.
If the U.S. wants the benefits of concierge-style care for everyone, policymakers and payers would need to reform primary care financing — paying for time, relationships, and prevention, not just procedures and visits.
It’s great when the Chatbot confirms my opinions and reinforces my biases. Travel this week limits my time to go further. Perhaps that is a good thing. I plan to return to the subject in the near future. I won’t be castigating concierge care, but I will speculate how in a difierent political environment we might be able to extend the benefits—better access, more efficent care, and a more personal relatonship with providers who know them— that the wealthy can now enjoy in the concierge environment to everyone because there is no moral basis for a two tiered medical system since much of what we now want from healthcare at its best is heavily dependent on public funding. Stay tuned, and feel free to tell me that the point of view I share with the good Dr. Beers is totally wrong.
Where’s All The Crime in Portland?
If you have never been to the Pacific Northwest, put a trip to Oregon, Washington, and British Columbia on your must-do bucket list. Our friends Doug and Leslie have recently downsized to a home adjacent to a lovely park at the top of an old extinct volcano in the middle of Portland, Mount Tabor. The header for this post is a view of the city from near the top of the mountain on an overcast morning, taken during an enjoyable walk on wide, well-groomed trails.
On a clear day, there are many places in Portland with stunning views of many of the more well-known mountains of the Cascades, all volcanoes, and some of which can erupt again. We were in Portland visiting Doug in 1984, when Mount St. Helens was still smoking four years after its 1980 eruption, when it had literally blown its top. As we have done many times, we decided to drive to Mount Hood, about an hour east of Portland. We wanted to enjoy the view and take in views of the mountain peak while having lunch at the historic Timberline Lodge. Below is the view of Mt. Hood from many miles away.
The beautiful Timberline Lodge is halfway up the mountain. As its name implies, it is at the timberline on the mountain. There are trees below, but not many above the lodge, which sits at 6,000 feet toward the 11,000-foot summit. The Lodge was built in 1937-38 by the craftsmen and craftswomen employed by the WPA, the Works Project Administration, which was part of FDR’s New Deal Response to the Great Depression. Roosevelt dedicated the magnificent structure in 1938. Timberline Lodge was not the only beautiful lodge built by the WPA during the late 30s. Over the years, I have visited or stayed for a few days at several of these wonderful creations. A companion alphabet program of the New Deal was the Civilian Conservation Corps (CCC), which built many trails in our National Parks and many structures that still benefit all Americans. It is good to remember that in our past, we have had innovative leaders who responded to what seemed like overwhelming challenges and led us to remarkable things that still endure over 85 years later.
Yesterday, after saying goodbye to our friends in Portland, we flew to California. We will be attending Grandparents’ Day at our oldest grandson’s school in Santa Cruz, about the time this letter comes to you. It is also his father’s forty-third birthday.
Life is good despite all the recent political uncertainty. I hope that you are looking forward to a great Thanksgiving week. I am glad to report that the airports were efficient and all our flights were on time or better. I am hoping that is true again on Monday when we fly home.
Be well,
Gene
