One name repeatedly crops up in these discussions: Valley Medical Group.

With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office in Florence can be found right on Main Street, next door to a pizza restaurant and near a Friendly’s.

Valley has 90 medical providers — including doctors, nurse practitioners, and physician assistants — and on-site labs, X-rays, and vision care. With tens of thousands of patients, it’s become one of the largest independent practices in western Massachusetts.

It forms a key part of the region’s health care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.

Despite patient demand — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician . Rates are outlined in the group’s contracts with insurance providers.

“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”

Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.

In response, many are banding together to form or IPAs. The goal is to increase their market power, change the way they get paid, and retain control over how they treat patients.

Threats to Physician Autonomy

Primary care practices in the U.S. are in serious trouble, according to workforce surveys. The American Association of Medical Colleges of up to 86,000 primary care doctors by 2036, as more primary care doctors retire and fewer enter the field.

The number of people who can’t find a primary care doctor has grown by 20% in the past decade, according to a .

Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted doctors can earn more in specialties such as cardiology or surgery.

Financial stresses in U.S. health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.

The released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get worse when the Republican-backed cuts to Medicaid start to take effect later this year.

As they seek financial security, many primary care practices have merged with large hospital systems, with doctors becoming employees of those systems.

But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.

“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”

By contrast, primary care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.

In December, Valley Medical Group announced it would be . Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.

“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of , an independent health care consultancy that works with health systems and physician groups.

IPAs are gaining momentum as older doctors retire, especially following the challenging years of the covid pandemic, Bielamowicz said. “As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”

The , a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.

“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said , a vice president at AAFP.

IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary care practices, maintaining access and options for insured patients.

Otherwise, some doctors shift their business model to “direct primary care,” which bypasses insurance altogether.

“We’re looking at independent practices that aren’t buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported,” said , a vice president with .

A Different Payment Model

When those independent practices band together, Glenn said, Blue Cross can offer . Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient’s care, which provides an incentive to keep them healthy so they need fewer treatments.

Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” TrustWorks’ Bielamowicz said.

If there is money left at the end of the year, it’s split between the practice and the insurer.

The catch, Glenn said, is that a value-based contract works only if there’s a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”

Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.

But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.

“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of in Cambridge, Massachusetts, the IPA specializing in value-based contracts that Valley Medical joined. “And we create more income for the PCPs [primary care providers], which is dreadfully needed.”

These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some of the less complex medical tasks, saving the practice money.

IPAs Can Help, Depending on Who’s in Charge

But IPAs are not a panacea for primary care’s problems, according to some health care leaders.

There are hundreds of IPAs, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they’re less focused on preventive care.

The American Academy of Family Physicians advises its members to seek out IPAs with “integrity,” ones that give doctors a strong role in decision-making.

“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.

Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.

That can be a hard sell, said Glenn, of Blue Cross. Under that payment model, doctors might see a lag of more than a year from the time they provide care to the moment they realize savings.

“It doesn’t happen overnight, and it does take an investment,” she said.

That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and, most important, keep the doctors in charge.

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Pero eso es lo que los empleados estatales de Massachusetts intentan hacer a diario, entre los sonidos y las luces intermitentes de las máquinas tragamonedas.

En el MGM Springfield, al oeste del estado, empleados con remeras verdes se encuentran frente a su pequeña oficina, justo al lado del casino.

Sobre ellos, un cartel dice el programa insignia del estado para combatir la ludopatía (adicción al juego). Una pantalla muestra mensajes como “Mantén las apuestas deportivas divertidas. Establece un presupuesto y cúmplelo”.

Los empleados reparten etiquetas para maletas y pañuelos desechables gratuitos para animar a la gente a charlar. Si lo consiguen, entregan a los clientes folletos con el número de teléfono estatal de ayuda para jugadores y su sitio web. Incluso pueden inscribirlos en , que permite a las personas establecer un presupuesto fijo mensual para sus apuestas.

Fuera de los casinos, GameSense se promociona en redes sociales, aplicaciones y sitios web de . Mientras tanto, el Departamento de Salud Pública del estado coloca en autobuses y vallas publicitarias.

“Es un gran movimiento de 12 años”, dijo , quien supervisa el programa GameSense en Massachusetts.

El primer casino de Massachusetts abrió sus puertas en 2015 y, a medida que la industria del juego crecía, el estado desarrolló lo que denomina un programa de “juego responsable”, financiado con un impuesto adicional sobre las ganancias de la industria.

Al principio, los reguladores estatales probaron diversas estrategias para educar a los clientes sobre la naturaleza adictiva del juego y sobre sus riesgos financieros.

“Se trataba más bien de asegurar la disponibilidad de folletos que explicaran las probabilidades de cualquier juego”, explicó Vander Linden.

Desde entonces, Massachusetts ha implementado para una industria en auge que ahora incluye las apuestas deportivas generalizadas.

Por ejemplo, no se pueden apostar sobre equipos universitarios de Massachusetts ni jugar con tarjeta de crédito. Todas las empresas de juegos de azar deben permitir a los clientes establecer límites voluntarios e inscribirse en una “lista de autoexclusión voluntaria” que les prohíbe el acceso a casinos o apuestas deportivas durante determinados intervalos de tiempo.

Un mosaico de normas estatales

Algunos estados han establecido límites similares para frenar la ludopatía, pero otros tienen muy pocos. A falta de una política nacional o de una comisión nacional del juego que supervise la industria, cada estado elabora su propio plan.

Un número creciente de investigadores y legisladores en materia de adicciones afirman que es hora de tomar medidas más audaces y unificadas para combatir los trastornos del juego.

Resaltan el auge de la industria del juego desde 2018, cuando la Corte Suprema de Estados Unidos a que los estados y desató una industria agresiva, ahora legal en 39 estados. (Cuarenta y ocho estados han legalizado al menos alguna forma de juego, incluyendo las loterías).

Otros países en la regulación de la industria del juego, y algunos expertos estadounidenses los consideran modelos potenciales.

Por ejemplo, el tiene el monopolio de todas las máquinas tragamonedas, lo que le permite controlar los tipos de juegos que se ofrecen, y cada jugador del país tiene un límite de pérdida de 20.000 coronas (unos $2.000) al mes.

En el , la mayoría de los adultos tienen (unos $7) por cada giro en una máquina tragamonedas, y las empresas de juegos de azar están sujetas a un impuesto del 1% que se destina a un fondo para el tratamiento y la prevención de los trastornos del juego.

El año pasado, un informe publicado en la revista médica instó a los líderes de salud internacionales a actuar con rapidez en las regulaciones antes de que los trastornos del juego se generalicen y se vuelvan comunes, y mucho más difíciles de detener.

Sin embargo, los líderes políticos señalan que Estados Unidos tiene menos interés en la regulación corporativa que muchos otros países, especialmente bajo la administración Trump. Al mismo tiempo, advierten que no hacer nada podría representar una grave amenaza para la salud pública, en especial ahora que las aplicaciones de apuestas deportivas permiten a las personas apostar en cualquier lugar y en cualquier momento.

El temor: más apuestas, más adicción

Incluso antes del “matrimonio” entre los juegos en línea y los teléfonos celulares, los investigadores estimaban que entre el y el de los estadounidenses ya padecían un trastorno del juego, y que un 8% adicional de desarrollarlo.

Algunos políticos estadounidenses temen que el problema solo empeore.

“La sofisticación y complejidad de las apuestas se han vuelto abrumadoras”, declaró el  (demócrata de Connecticut). “Y por eso necesitamos protecciones que permitan a las personas decir que no”.

Blumenthal ha copatrocinado el (la Ley de Apuestas Seguras), una legislación que impondría normas federales a las empresas de apuestas deportivas.

El proyecto de ley propone la prohibición de la publicidad de juegos de azar durante eventos deportivos en vivo, controles obligatorios de asequibilidad para clientes con grandes gastos, límites a los programas de membresía VIP, la prohibición del uso de la inteligencia artificial para marketing y la creación de una base de datos nacional de “autoexclusión”, entre otras normas.

“Los estados no pueden proteger a sus consumidores de las ofertas excesivas y abusivas, y a veces de los anuncios engañosos”, declaró Blumenthal. “Simplemente no tienen los recursos ni la jurisdicción”.

La industria del juego se opone firmemente a esta ley. Las normas federales serían una bofetada para los reguladores estatales, afirmó Joe Maloney, vocero de la .

“Tienen el potencial de, primero, usurpar drásticamente la autoridad de los estados y, segundo, congelar la industria”, afirmó.

El juego responsable y la salud pública

Las nuevas regulaciones también son innecesarias, afirmó Maloney. La industria reconoce que el juego es adictivo para algunas personas, explicó, por lo que desarrolló una iniciativa de divulgación y concientización conocida como .

Esto incluye mensajes en autobuses y carteles que advierten a la gente que deje de jugar cuando ya no sea divertido y les recuerdan que las probabilidades de ganar son muy bajas.

“Hay mensajes muy directos, como: ‘Aquí perderás dinero’”, dijo Maloney.

Agregó que su grupo industrial no recopila datos sobre si tales medidas reducen las tasas de adicción. Sin embargo, afirmó que las restricciones al juego no son la solución.

“Si de repente se empieza a elegir entre lo legal y lo prohibido, se está alejando a los apostadores del mercado legal y llevándolos al ilegal”, afirmó Maloney.

Los líderes de salud pública argumentan que el modelo de “juego responsable” de la industria no funciona.

“Se necesita regulación cuando la industria ha demostrado incapacidad y falta de voluntad para autocontrolarse”, afirmó , director de políticas de juego del de la Facultad de Derecho de la Universidad de Northeastern en Boston.

Una de las razones por las que el enfoque de la industria es “ética y científicamente defectuoso” es que atribuye toda la culpa y la responsabilidad a las personas con un trastorno del juego, afirmó Levant. “No se puede decir a una persona que lucha contra la adicción: ‘Bueno, simplemente deja de hacerlo’”.

Levant aborda el tema desde su experiencia personal. Se está recuperando de una adicción al juego. Ex abogado, fue por robar dinero de sus clientes para financiar su adicción al juego. Desde entonces, no solo se ha convertido en un defensor de regulaciones más estrictas, sino que también es un terapeuta especializado en adicciones.

La American Gambling Association (AGA) afirmó apoyar el tratamiento de los trastornos del juego y ayudar a financiar algunos servicios de derivación y tratamiento a través de impuestos estatales. Sin embargo, Levant calificó esto como “el equivalente moral de que las grandes tabacaleras digan: ‘Hagamos lo que queramos con nuestros cigarrillos, siempre y cuando paguemos la quimioterapia y los cuidados paliativos'”.

En cambio, Levant aboga por un enfoque de salud pública que ayude a prevenir la adicción de raíz. Esto significa limitar la publicidad, y los tipos y la frecuencia de las apuestas, para todos, no solo para quienes ya tienen problemas.

Para defender su postura, Levant abre su computadora y muestra un anuncio corporativo producido por Simplebet, .

En el video, la compañía presume de conseguir que más gente apueste en deportes mediante las llamadas microapuestas durante los partidos en directo. “Impulsamos la participación de los aficionados convirtiendo cada momento de cada partido en una oportunidad para apostar. Automático, algorítmico, impulsado por el aprendizaje automático y la IA”, dice la voz en off.

Ese es el tipo de participación constante que fomenta la adicción, afirmó Levant. (Contactados por Â鶹ŮÓÅ Health News y NPR, DraftKings declinó hacer comentarios y, en su lugar, envió un enlace a su ).

Legisladores quieren actuar ya

Algunos de estos mecanismos de juego se verían limitados por la Ley de Apuestas Seguras, que Levant y sus colegas del Instituto de Defensa de la Salud Pública ayudaron a redactar.

Pero si la legislación no se aprueba en el actual Congreso, reacio a las regulaciones, los estados deberán tomar medidas contundentes por su cuenta, afirmó Levant.

La Legislatura de Massachusetts está considerando actualmente la “Ley de Salud del Apostador” (), que impondría normas adicionales a las empresas de apuestas deportivas.

“El objetivo no es eliminar por completo las apuestas”, dijo

La representante estatal de Massachusetts, la demócrata , copatrocinadora del proyecto de ley, dijo: “Es para detener los peores excesos de las apuestas deportivas en línea”.

El proyecto de ley de Massachusetts incluye componentes de la legislación federal, como los controles de asequibilidad obligatorios. Estos limitarían la cantidad de dinero que algunos jugadores pueden perder. Los controles de asequibilidad se basan en del Reino Unido.

“Si solo te permiten tomar dos copas, sabemos que no te vas a emborrachar, ¿verdad?”, dijo Sabadosa. “Si solo te permiten apostar $100 al día porque es una cantidad asequible, no te arruinarás. Podrás pagar el alquiler”.

La Ley de Salud del Apostador también prohibiría las apuestas “prop”, que son apuestas realizadas durante un partido en vivo, como quién marca el primer tiro en baloncesto o quién conecta el primer jonrón en béisbol.

Sin embargo, los provenientes de las apuestas deportivas ascendieron a $2.800 millones en 2024, una fuente de financiación muy útil para los presupuestos estatales con dificultades. Debido a este posible impulso, Levant teme que los gobiernos estatales eviten una mayor regulación.

Los estados podrían incluso verse tentados por la promesa de ingresos adicionales provenientes de nuevos tipos de juegos de azar, como el “iGaming”. Se refiere a las versiones en línea de la ruleta, el blackjack y otros juegos de casino, disponibles a cualquier hora, desde la comodidad del hogar.

Actualmente, el iGaming es legal en siete estados, pero la legislación pendiente en otros estados, , podría expandir sus mercados.

“Comprendemos lo difícil que es para los estados equilibrar sus presupuestos en el actual entorno político”, declaró Levant, “pero están empezando a reconocer que la solución a ese problema no es seguir impulsando un producto conocido por ser adictivo”.

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But that’s what Massachusetts state workers try to do every day, amid the clanging bells and flashing lights of the slot machines.

At the MGM Springfield in western Massachusetts, workers wearing green polos stand outside their small office, right off the casino floor.

Above them, a the state’s signature program to curb problem gambling. A mounted screen cycles through messages such as “Keep sports betting fun. Set a budget and stick to it.”

The workers hand out free luggage tags and travel-size tissues to encourage people to stop and chat. If they succeed, they give customers brochures displaying the state’s gambling helpline number and website. They can even enroll them in a which allows customers to set monthly spending limits on how much they gamble.

Outside the casinos, GameSense is marketed on social media and on and websites. Meanwhile, the state’s Department of Public Health puts its own on buses and billboards.

“That’s a big movement in 12 years,” said , who oversees the GameSense program in Massachusetts.

Massachusetts’ first casino opened in 2015, and as the gaming industry grew, the state developed what it calls a “responsible gaming” program, funded by a surtax on gambling industry profits.

At first, tried various strategies to educate customers about the addictive nature of gambling, as well as the financial risks.

“It was much more about making sure that there are brochures that are available that explained the odds of whatever game it was,” Vander Linden said.

Since then, Massachusetts has put in place on a booming industry that now includes widespread sports betting. For example, there’s no betting on Massachusetts college teams, and no gambling by credit card. All gambling companies must allow customers to set voluntary limits and sign up for a “voluntary self-exclusion list” that bans them from casinos or sports betting over various time intervals.

A Patchwork of State Policies

Some states have set similar limits to curb problem gambling, but others have very few. In the absence of a nationwide policy, or a national gambling commission to oversee the industry, each state is on its own. 

A growing number of addiction researchers and policymakers say it’s time to take bolder — and more unified — steps to combat gambling disorders. They point to the explosion of the gaming industry since 2018, when the U.S. Supreme Court for states to and unleashed an aggressive industry, now legal in 39 states. (Forty-eight states have legalized at least some form of gambling, including lotteries.)

Compared with the U.S., several other countries have the gambling industry, and some experts in the U.S. are looking to them as potential models.

For example, has a monopoly on all slot machines so it can control the types of games offered, and every gambler in the country is limited to losing 20,000 kroner (about $2,000) a month.

In the , most adults are limited to on every spin on a slot machine, and gambling companies are subject to a 1% levy that goes into a fund for treatment and prevention of gambling disorders.

Last year, a report published in the medical journal called on international health leaders to act quickly on regulations before gambling disorders become widespread and common — and that much harder to stop.

But policy leaders point out that the U.S. has less appetite for corporate regulation than many other countries, especially under the Trump administration. At the same time, they warn that doing nothing could pose a serious public health threat, especially now that sports betting apps allow people to gamble anywhere and anytime.

Fears That More Gambling Means More Addiction

Even before the marriage of online gaming and cellphones, researchers had estimated to of Americans already had a gambling disorder, and an additional 8% of people were of developing one.

Some U.S. politicians fear the problem will only get worse.

“The sophistication and complexity of betting has become staggering,” said Democratic of Connecticut. “And that’s why we need protections that will enable an individual to say no.”

Blumenthal has cosponsored the , legislation that would impose federal standards on sports betting companies.

The bill proposes a ban on gambling ads during live sporting events, mandatory “affordability checks” for high-spending customers, limits on VIP membership schemes, a ban on artificial intelligence tracking for marketing, and the creation of a national “self-exclusion” database, among other rules.

“States are unable to protect their consumers from the excessive and abusive offers, and sometimes misleading pitches,” Blumenthal said. “They simply don’t have the resources or the jurisdiction.”

The gambling industry is strongly opposed to the SAFE Bet Act. Federal standards would be a “slap in the face” to state regulators, said Joe Maloney, a spokesperson for the .

“You have the potential to just dramatically, one, usurp the states’ authority and then, two, freeze the industry in place,” he said.

‘Responsible Gaming’ Versus the Public Health Approach

New regulations are also unnecessary, Maloney said. The industry acknowledges that gambling is addictive for some people, he said, which is why it developed an outreach/awareness initiative known as “.”

That includes messages on buses and billboards warning people to stop playing when it’s no longer fun and reminding them the odds of winning are very low.

“There’s very direct messages, such as, ‘You will lose money here,’” Maloney said.

He said his industry group does not collect data on whether such measures reduce addiction rates. But he said gambling restrictions are not the answer.

“If you suddenly start to pick and choose what can be legal or banned, you’re driving bettors out of the legal market and into the illegal market,” Maloney said.

Public health leaders argue that the industry’s “responsible gaming” model doesn’t work.

“You need regulation when the industry has shown an inability and unwillingness to police itself,” said , director of gambling policy for the at the Northeastern University School of Law in Boston.

One reason the industry’s approach is “ethically and scientifically flawed” is that it puts all the blame and responsibility on individuals with a gambling disorder, Levant said. “You can’t say to a person who is struggling with addiction, ‘Well, just don’t do that anymore.’”

Levant comes to the issue from personal experience. He is in recovery from a gambling addiction. A former lawyer, Levant was for stealing clients’ money to fund his betting habit. Since then, he not only has become an advocate for stronger regulations but also is a trained addiction therapist.

The American Gaming Association said it supports treatment for gambling disorders and helps pay for some referral and treatment services through state taxes. But Levant called that “the moral equivalent of Big Tobacco saying, ‘Let us do whatever we want for our cigarettes, as long as we pay for chemotherapy and hospice.’”

Instead, Levant advocates for a public health approach that would help prevent addiction from the get-go. That means putting limits on marketing and on the types, and frequency, of gambling — for everyone, not just those already in trouble.

To make his case, Levant opens his laptop and pulls up a corporate infomercial produced by Simplebet, a .

In the video, the company boasts about getting more people to gamble on sports through what’s called microbetting during live games. “We drive fan engagement by making every moment of every game a betting opportunity. Automatic, algorithmic, powered by machine learning and AI,” the voiceover said.

That’s the kind of constant engagement that promotes addiction, Levant said. (Contacted by Â鶹ŮÓÅ Health News and NPR, DraftKings declined to comment, instead sending a link to its .)

Lawmakers Want To ‘Stop the Worst Excesses’ Before the Next Gambling Trend

Some of those gambling mechanisms would be limited by the SAFE Bet Act, which Levant and his colleagues at the Public Health Advocacy Institute helped write.

But if the legislation doesn’t get through the current regulation-averse Congress, then states need to take strong action on their own, Levant said.

The Massachusetts Legislature is currently considering the “,” which would impose additional rules on sports betting companies.

“The goal is not to stop gambling entirely,” said Massachusetts state , a cosponsor of the bill. “It’s to stop the worst excesses of online sports betting.”

The Massachusetts bill includes components of the federal legislation, such as mandatory “affordability checks.” Those would cap how much money some gamblers can lose. Affordability checks are modeled on a in the United Kingdom.

“If you’re only allowed to have two drinks, we know that you’re not going to get drunk, right?” Sabadosa said. “If you’re only allowed to gamble $100 a day because that’s an affordable amount, you’re not going to go broke. You’re still going to be able to pay the rent.”

The Bettor Health Act would also ban “prop” bets, which are wagers placed during a live game, such as who makes the first shot in basketball, or who hits the first home run in baseball.

But from sports betting rose to $2.8 billion in 2024 — a welcome source of funding for struggling state budgets. Because of that potential boost, Levant fears that state legislatures will shy away from further regulation.

States may even be tempted by the promise of additional revenue from new types of gambling, such as “iGaming.” That refers to online versions of roulette, blackjack, and other casino-style games, playable at any hour, from the comfort of home.

IGaming is currently legal in seven states, but pending legislation in other states, , could expand its markets.

“We have empathy for how hard it is for states to balance their budgets in this current political environment,” Levant said, “but states are starting to recognize that the answer to that problem is not to further push a known addictive product.”

This article is part of a partnership with and .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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“You’d call and you’re talking about weeks to a month,” Andrews said.

That’s not surprising, as many workplace surveys show the supply of primary care doctors has fallen well below the demand, especially in rural areas such as western Massachusetts. But Andrews still wasn’t prepared for the letter that arrived last summer from her doctor, Christine Baker, at .

“We are writing to inform you of an exciting change we will be making in our Internal Medicine Practice,” the letter read. “As of September 1st, 2024, we will be switching to Concierge Membership Practice.”

Concierge medicine is a business model in which a doctor charges patients a monthly or annual membership fee — even as the patients continue paying insurance premiums, copays, and deductibles. In exchange for the membership fee, doctors limit their number of patients.

Many physicians who’ve made the change said it resolved some of the pressures they faced in primary care, such as having too many patients to see in too short a time.

Andrews was floored when she got the letter. “The second paragraph tells me the yearly fee for joining will be $1,000 per year for existing patients. It’ll be $1,500 for new patients,” she said.

Although numbers are not tracked in any one place, the trade magazine Concierge Medicine Today estimates there are concierge physicians in the U.S. Membership fees range from $1,000 to as high as $50,000 a year.

Critics say concierge medicine helps only patients who have extra money to spend on health care, while shrinking the supply of more traditional primary care practices in a community. It can particularly affect rural communities already experiencing a shortage of primary care options.

Andrews and her husband had three months to either join and pay the fee or leave the practice. They left.

“I’m insulted and I’m offended,” Andrews said. “I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”

Baker, Andrews’ former physician, said fewer than half her patients opted to stay — shrinking her patient load from 1,700 to around 800, which she considers much more manageable. Baker said she had been feeling so stressed that she considered retiring.

“I knew some people would be very unhappy. I knew some would like it,” she said. “And a lot of people who didn’t sign up said, ‘I get why you’re doing it.’”

Patty Healey, another patient at Baker’s practice, said she didn’t consider leaving.

“I knew I had to pay,” Healey said. As a retired nurse, Healey knew about the shortages in primary care, and she was convinced that if she left, she’d have a very difficult time finding a new doctor. Healey was open to the idea that she might like the concierge model.

“It might be to my benefit, because maybe I’ll get earlier appointments and maybe I’ll be able to spend a longer period of time talking about my concerns,” she said.

This is the conundrum of concierge medicine, according to Michael Dill, director of workforce studies at the . The quality of care may go up for those who can and do pay the fees, Dill said. “But that means fewer people have access,” he said. “So each time any physician makes that switch, it exacerbates the shortage.”

the U.S. will face a shortage of within the next decade.

found that the percentage of residents in western Massachusetts who said they had a primary care provider was lower than in several other regions of the state.

Dill said the impact of concierge care is worse in rural areas, which often already experience physician shortages. “If even one or two make that switch, you’re going to feel it,” Dill said.

Rebecca Starr, an internist who specializes in geriatric care, recently started a concierge practice in Northampton.

For many years, she consulted for a medical group whose patients got only 15 minutes with a primary care doctor, “and that was hardly enough time to review medications, much less manage chronic conditions,” she said.

When Starr opened , she wanted to offer longer appointments — but still bring in enough revenue to make the business work.

“I did feel a little torn,” Starr said. While it was her dream to offer high-quality care in a small practice, she said, “I have to do it in a way that I have to charge people, in addition to what insurance is paying for.”

Starr said her fee is $3,600 a year, and her patient load will be capped at 200, much lower than the 1,000 or even 2,000 patients that some doctors have. But she still hasn’t hit her limit.

“Certainly there’s some people that would love to join and can’t join because they have limited income,” Starr said.

Many doctors making the switch to concierge medicine say the membership model is the only way to have the kind of personal relationships with patients that attracted them to the profession in the first place.

“It’s a way to practice self-preservation in this field that is punishing patients and doctors alike,” said internal medicine physician Shayne Taylor, who recently opened offering “direct primary care” in Northampton. The direct primary care model is similar to concierge care in that it involves charging a recurring fee to patients, but bypasses insurance companies altogether.

Taylor’s patients, capped at 300, pay her $225 a month for basic primary care visits — and they must have health insurance to cover care such as X-rays and medications, which her practice does not provide. But Taylor doesn’t accept insurance for any of her services, which saves her administrative costs.

“We get a lot of pushback because people are saying, ‘Oh, this is elitist, and this is only going to be accessible to people that have money,’” Taylor said.

But she said the traditional primary care model doesn’t work. “We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company.”

While much of the pushback on the membership model comes from patients and policy experts, some of the resistance comes from physicians.

, a primary care doctor who runs in western Massachusetts, said his practice is more stretched than ever. One reason is that the group’s clinics are absorbing some of the patients who have lost their doctor to concierge medicine.

“We all contribute through our tax dollars, which fund these training programs,” Carlan said.

“And so, to some degree, the folks who practice health care in our country are a public good,” Carlan said. “We should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public.”

But Taylor, who has the direct primary care practice, said it’s not fair to demand that individual doctors take on the task of fixing a dysfunctional health care system.

“It’s either we do something like this,” Taylor said, “or we quit.”

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