Two Americans Walk Into a Doctor's Office...
One gets same-day access and a physician who knows their name. The other waits 31 days and sees whoever is available.
A patient came to see me recently after spending eight months trying to get an accurate diagnosis through her primary care physician. Eight months. Four appointments with different physicians she had never met before. Conflicting assessments. A referral that took six weeks to schedule. A follow-up that required another six weeks.
She was not uninsured. She had employer-sponsored coverage from a mid-sized company. By every conventional metric, she had access to the healthcare system.
She had access to a waiting room. That is not the same thing.
Meanwhile, in the same city, there are physicians whose practices limit their patient panel to 400 people, who return calls the same day, who know their patients’ names, families, histories, and health goals, and who will see them within hours of a concern arising. Those practices charge $200 to $300 per month, in addition to insurance. For the people who can afford that fee, the healthcare system works exactly as advertised.
For everyone else, it works as described above.
This is not a future risk. It is the present reality of American healthcare. And it is accelerating.
The Market That Is Telling You Everything
The concierge medicine market is projected to grow from $20.6 billion in 2024 to $47 billion by 2034, an 8.6% compound annual growth rate.
Markets do not grow at that rate unless they are solving a problem that the existing system has failed to solve. The concierge medicine market is growing because the standard healthcare system has become so inaccessible, so impersonal, and so administratively hostile that a significant and growing segment of the population is willing to pay a second time, on top of their insurance premiums, just to receive care that resembles what healthcare is supposed to look like.
Concierge physicians limit patient panels to 400 to 500 individuals, compared to traditional primary care loads exceeding 2,000 patients. That ratio difference is the entire story. A physician with 2,000 patients cannot know those patients. Cannot track their history. Cannot notice the pattern across three separate visits that suggests something being missed. The cognitive and administrative load of that panel size makes continuity of care structurally impossible.
The concierge model does not represent a medical breakthrough. It represents a return to the conditions under which medicine was always supposed to be practiced, at a price point that excludes most of the country.
The 31-Day Wait That Has Become Normal
In just the last three years, the time needed to schedule a physician appointment increased by 19% in 15 of the largest cities in the country. That time has grown 48% since 2004, according to the 2025 AMN Healthcare Survey of Physician Appointment Wait Times.
The national average wait for a primary care appointment is now 31 days. For an OB-GYN, the average is 42 days, up 79% since 2004. For a cardiologist, 33 days, up 74%.
Thirty-one days to see a primary care physician. Not for a complex procedure. Not for a specialist. For the baseline clinical relationship that is supposed to anchor every patient’s healthcare journey.
When the wait is 31 days, patients do one of several things. They go to urgent care and see whoever is working that shift. They go to the emergency department, which costs twelve times more than a physician office visit and adds to a national estimate of $32 billion in avoidable ED spending annually. They wait. And while they wait, conditions that were manageable become acute. Symptoms that were early become advanced. The diagnosis that would have been straightforward at week one becomes complicated at week five.
The concierge patient calls their physician directly. Gets a same-day response. Has a 45-minute appointment with someone who has reviewed their chart before walking in the room.
These are not different levels of a shared system. They are two different systems operating in the same country, increasingly diverging, and almost nobody with power to change it is naming the divergence honestly.
What This Looks Like From My Specific Vantage Point
I am an orthopedic surgeon. My direct clinical experience with this two-tier reality is not in primary care access. It is in surgical outcomes.
The patients who arrive in my operating room in the best condition are, without exception, the patients who have had consistent, high-quality primary care management of their chronic conditions. Their diabetes is controlled. Their inflammation is managed. Their cardiovascular risk is addressed. When they need a joint replacement, the surgical environment is optimized because the medical environment around it has been well managed.
The patients who arrive in the worst condition, mechanically and metabolically, are the ones who have been navigating a fragmented, overcrowded system with a physician who sees them for seven minutes twice a year and has 1,993 other patients competing for attention. Their comorbidities are undertreated. Their pre-operative preparation is inadequate. The surgery is the same. The outcome is measurably worse.
This is not speculation. It is what I see. And the difference in outcome maps almost perfectly onto the difference in primary care access, which maps almost perfectly onto income.
The Two Arguments the System Makes to Justify This
I want to name the two arguments that defenders of the status quo make, because they are not entirely wrong, and because treating them as entirely wrong is intellectually dishonest.
The first argument is that concierge medicine is just a market response to consumer preferences. People who can pay more get more, as in every other industry. The second argument is that direct primary care and lower-cost membership models are expanding access beyond the wealthy, democratizing the model somewhat.
Both have some truth in them.
The direct primary care movement has produced practices charging $50 to $80 per month for membership, genuinely extending personalized access to working-class patients in some markets. That is real progress and I do not dismiss it. The market differentiation argument is also factually accurate: premium services have always existed in every industry.
The problem is applying industry logic to a system where the consequences of unequal access are not inconvenience, they are clinical outcomes. When premium access means better cancer screening, earlier intervention on cardiovascular risk, and better-managed chronic disease, the differential is not a luxury gap. It is a health outcome gap. And that gap compounds over decades.
The patient who waited 31 days for a primary care appointment and then got seven minutes with a physician managing 2,000 patients is not just underserved in an abstract sense. They will, statistically, present to a surgeon later, in worse condition, with more comorbidities, and recover less completely than the patient who had a physician who knew them.
I see that outcome every week. With my hands.
What Indiana Orthopedic Institute Was Built to Prove
When I founded IOI, one of the foundational questions was whether the physician-led, patient-centered care model requires patients to be wealthy to access it.
Our answer, operationally, is no. But the structural conditions that make that possible are specific and deliberate.
The ASC model drives down procedure costs by eliminating the hospital overhead that inflates the price of care without improving its quality. Transparent pricing means patients can make actual decisions rather than opening a bill six weeks after the fact and discovering something they had no way to anticipate. Physician ownership aligns the incentives in the room around the patient’s outcome rather than the institution’s margin.
A patient accessing care at Indiana Orthopedic Institute is not paying a concierge premium. They are accessing physician-led care at a cost structure that the hospital employment model cannot compete with on price, quality, or access, because the hospital model was not designed for any of those outcomes. It was designed for institutional revenue.
The model is replicable. That is the point. The alternative to a two-tier system is not taxing the concierge practices out of existence. It is building the infrastructure that makes physician-led, patient-centered care economically accessible to people who are not wealthy. That infrastructure is the ASC. That infrastructure is transparent pricing. That infrastructure is physician ownership.
It will not be built by the hospital systems that benefit from the current model. It has to be built by the physicians who have both the clinical standing and the entrepreneurial will to build it.
What the Two-Tier System Is Actually Telling Us
The explosive growth of concierge medicine is not a sign that wealthy people are getting greedy about their healthcare.
It is a market signal. A signal that the standard healthcare delivery model has failed to provide the basic conditions of a functional physician-patient relationship at scale. When a $250 per month membership fee is the price of having a physician who knows your name, the standard model has failed. That failure is being papered over by urgent care centers, telemedicine platforms, and mid-level provider substitution. None of those are bad things in themselves. None of them replace the physician relationship that produces the best long-term clinical outcomes.
The wealthy are opting out of that failure with their checkbooks. The rest of America is navigating it with 31-day wait times, seven-minute appointments, and a system that has optimized for throughput at the direct expense of the care quality that throughput is supposed to deliver.
That is not an acceptable outcome. And the physicians who have the credibility, the operational knowledge, and the genuine anger on behalf of patients to say so publicly should be saying it.
This is me saying it.
