Why I Left the Insurance Fee-for-Service Model of Primary Care

By Christopher L. Bray, MD, PhD, CPE, FACP Founder, Archangel Michael Health | Direct Primary Care & Integrative Medicine

I spent nearly 18 years inside the traditional insurance-based, fee-for-service model of primary care. I did not leave it casually, or because something easier came along. I left because I could no longer, in good conscience, deliver the kind of medicine I was trained to practice — and because the system I was working inside had stopped serving my patients in any meaningful way.

This article is for both patients and physicians. If you are a patient wondering why your doctor seems rushed, distracted, or checked out — this is why. If you are a physician wondering whether there is another way — there is. And if you are asking why my practice at Archangel Michael Health operates on a subscription membership model rather than billing your insurance for every visit — read on. The answer goes deeper than you might expect.

A System Built for Volume, Not for People

When I entered practice in 2007, the problems were already visible. Physician panels in primary care averaged around 2,300 patients per doctor. To care for a panel that size — managing their chronic diseases, preventive needs, and acute illnesses according to evidence-based guidelines — a single physician would need to work 21.7 hours per day, according to a landmark study in the Annals of Family Medicine. That is not a rounding error. That is a structural impossibility.

The math meant one thing in practice: you moved fast. Very fast. To keep up with overhead and administrative costs while accepting insurance reimbursements that declined year after year in real dollars, a primary care physician had to see 20 to 30 patients a day. The average visit became 18 minutes — and much of that time was not spent listening to the patient. It was spent staring at a screen.

A landmark time-and-motion study published in the Annals of Internal Medicine followed 57 physicians across 430 hours of observation. The finding was stark: physicians spent 27% of their time in face-to-face clinical time with patients, and 49% of their time on EHR and desk work. For every hour of direct patient care, physicians spent nearly two additional hours on documentation. A Massachusetts General Hospital study found that primary care physicians were logging 36 minutes of EHR time for visits scheduled at only 30 minutes. We were spending more time with our computers than with our patients.

I lived this. I remember days seeing 24 or 28 patients, each visit a sprint through a checklist — order the labs, issue the prescription, close the note, move on. Patients would arrive with six or eight or ten problems accumulated over months because getting an appointment was so difficult. They had legitimate, urgent concerns. And I had, at best, a few minutes to address them.

That is not medicine. That is triage.

The Quality Measures Trap

When fee-for-service medicine began losing its credibility as a quality framework, the insurance industry and CMS responded with quality measures — performance metrics that physicians were required to track and report in order to justify their reimbursements. The goal was understandable: reward good outcomes, not just high volume. The execution was a bureaucratic catastrophe.

CMS’s Merit-based Incentive Payment System (MIPS) alone encompassed 255 quality measures in 2019. NCQA’s HEDIS framework added over 90 more. Between 2008 and 2018, CMS developed more than 2,200 measures across 26 payment programs. At the practice level, this translated into an exhausting compliance performance at nearly every patient visit — regardless of what that patient had come in to discuss.

Here is what that looked like from the inside: A patient comes in with knee pain. Before I could properly attend to their knee, I was obligated to address the system’s agenda. Had I counseled them on vaccines this year? Screened them for depression and anxiety? Asked about falls risk and home safety? Assessed their BMI and documented obesity counseling? Confirmed they were on the correct guideline-directed medications for each of their chronic conditions? Each of these boxes — and dozens more — had to be checked, documented, and reportable in a format the insurance company could audit.

I want to be clear: many of these are clinically important topics. But performing a scripted review of 250 requirements during a 15-minute visit about an entirely different concern is not good medicine. It is compliance theater. And patients felt it. They could sense when their doctor was working through a list rather than actually listening to them.

The financial burden of this system was enormous. A study published in Health Affairs found that physicians and their staff were spending 785 hours per physician per year on quality measure reporting — at a cost of $40,069 per physician annually, totaling $15.4 billion nationwide across just four specialties. MedPAC, the independent advisory body to Congress on Medicare payment policy, ultimately voted 14 to 2 to recommend eliminating MIPS altogether, with the chair stating simply: “We came to the conclusion that, no, it’s simply not fixable.”

We were being paid — poorly, and after enormous administrative effort — to document that we had talked about things that may not have been relevant to why the patient was sitting in front of us. The AMA President described it bluntly: “You have to tap into the electronic health record all of these meaningless quality measures that don’t change what we do every day.”

Who Was the Doctor Actually Working For?

This is the question that drove me out.

In a fee-for-service, insurance-based model, the entity paying the physician is the insurance company — not the patient. The physician is reimbursed by documenting the correct ICD-10 diagnosis codes, the correct CPT procedure codes, and meeting the correct “required elements” of the visit note. Prior authorizations must be obtained before treatments can proceed. Quality measures must be met to avoid payment penalties. Documentation must be formatted to satisfy audit criteria.

None of these activities are oriented toward the patient’s wellbeing. They are oriented toward the insurance company’s compliance standards.

The patient, meanwhile, is paying premiums to the insurance company — not directly to the physician. Which means the patient also experiences the relationship as one with an insurance company, not with a doctor who knows them as a person. Over time, both parties stop experiencing medicine as a relationship and start experiencing it as a transaction. The physician becomes a service provider. The patient becomes a claimant. The humanity of the encounter — the trust, the continuity, the therapeutic value of being genuinely known by your doctor — erodes and eventually disappears.

I watched this happen. I watched patients become justifiably cynical. I watched colleagues burn out and leave medicine entirely. And the data bears this out on a national scale: according to the Medscape 2024 Physician Burnout & Depression Report, 49% of physicians reported burnout, with family medicine at 51%. The number-one driver, cited by 62% of burned-out physicians, was “too many bureaucratic tasks.” Separately, a nationally representative survey found that American trust in physicians plummeted from 71.5% in 2020 to just 40.1% by 2024. Decades of institutional behavior had their predictable result.

There is also a perverse incentive embedded in this model that I found increasingly indefensible: in fee-for-service medicine, a physician earns more when patients are sicker. If a patient with a chronic condition requires four visits in a year, that generates four billing events. The system is literally financially structured to reward illness, not health. The AAFP stated it plainly in its formal position paper: “The transactional nature of fee-for-service is fundamentally misaligned with the continuous patient relationships that drive the delivery of high-quality, comprehensive, coordinated and longitudinal primary care.”

That alignment problem was, ultimately, the thing I could not get past.

What Direct Primary Care Changes

Direct Primary Care (DPC) removes the insurance company as the middleman between patient and physician. Instead of billing a third party for every visit, the patient pays a flat monthly membership fee directly to their doctor, and that fee covers the full scope of primary care services. There are no copays, no deductibles, no per-visit charges, and no insurance submissions for primary care encounters.

The structural change this creates is profound. With insurance removed from the equation, the physician’s obligations are entirely to the patient. There are no quality measure boxes to perform. No prior authorization queues to work through. No RVU targets to hit. No coding auditors to satisfy. The visit is about one thing: you and your health.

DPC physicians intentionally limit their panel sizes. The national average, per AAFP 2024 data, is 413 patients — compared to 2,300 in a traditional practice. This is not a lifestyle choice. It is a prerequisite for the model to function as intended. A physician with 400 patients can return a call the same day. Can schedule you this week. Can spend 30 to 45 minutes with you when you are unwell. Can know your history, your family, your values, and your goals — not because they are a saint, but because they have the time to.

The incentive realignment is the part I find most important. Under DPC, my financial stability depends on my patients staying healthy enough that they continue to see value in their membership. If I am doing my job well — managing their chronic conditions proactively, catching problems early, keeping them out of the emergency room — they renew. The model pays me to prevent illness. That is what medicine is supposed to do.

What the Evidence Shows

The outcomes data for DPC, while still maturing, is directionally consistent. The most rigorous independent analysis — a risk-adjusted actuarial study by Milliman for the Society of Actuaries — found that DPC membership was associated with a 40.5% reduction in emergency department visits and a 12.6% reduction in overall healthcare demand. The Qliance Medical Group, one of the early large-scale DPC practices, documented 20% lower overall healthcare costs per 1,000 patients, with patient satisfaction at the 95th percentile nationally on standardized surveys. A 2025 survey of 1,534 DPC patients across 12 clinics achieved a Net Promoter Score of 85 — described by researchers as “world-class in any industry.”

For physicians, the transformation is equally striking. The AAFP’s 2024 data found that DPC physicians reported a satisfaction rate of 94% versus 57% among non-DPC physicians. Burnout among DPC physicians was measured at 12%, compared to 46% in traditional practice. Nearly half of DPC physicians reported experiencing no burnout at all.

These are not marginal differences. They represent a fundamentally different professional and patient experience.

DPC Is Not a Replacement for Insurance

I want to be clear about something that is frequently misunderstood. Direct Primary Care is not insurance, and it does not replace the need for insurance. You still need coverage for hospitalizations, surgeries, emergency care, specialist consultations, and catastrophic events. DPC is a better way to deliver primary care — the routine, preventive, and chronic disease management that constitutes the vast majority of most people’s healthcare interactions over a lifetime.

The model works well when paired with a high-deductible or catastrophic health insurance plan. The DPC membership handles what you actually use day to day; the insurance handles what you hope you never need. When combined, the total cost is often lower than a conventional comprehensive insurance premium with copays. And beginning January 1, 2026, DPC membership fees are now officially eligible for payment through Health Savings Accounts under the Primary Care Enhancement Act — making the model more financially accessible than ever for the estimated 61 million Americans with HSA-qualified plans.

Why I Built Archangel Michael Health This Way

I left residency program leadership after seven years and more than 160 residents trained. I had seen medicine from the top of the academic hierarchy. And I still could not reconcile the gap between what medicine could be and what the insurance system was making it into.

Archangel Michael Health exists as a Direct Primary Care practice because I believe primary care — genuine, longitudinal, relationship-based primary care — is the foundation of good health. Not a gateway to specialty referrals. Not a compliance station for insurance metrics. Not a transaction. A relationship.

Your membership at AMH is not just access to a physician. It is a commitment on my end: to know you, to have time for you, to answer your calls and messages without billing you for the interaction, to address your medical questions as your doctor rather than as a service provider completing a work order. The monthly fee is the structure that makes that possible — because it is what allows me to maintain a panel small enough that you are not a number in a queue.

The system broke the doctor-patient relationship over decades of misaligned incentives, impossible workloads, and administrative machinery that served everyone except the people in the room. Direct Primary Care is the most straightforward path I have found to rebuild it.

That is why I left. That is why I am here.

Dr. Christopher L. Bray, MD, PhD, CPE, FACP is a board-certified internist and integrative medicine physician and the founder of Archangel Michael Health, a Direct Primary Care practice serving patients across Florida, Georgia, Texas, North Carolina, and Arizona, with house calls in Alachua County, FL. Learn more or inquire about membership at archangelmichaelhealth.com.

References

Altschuler J, Margolius D, Bodenheimer T, Grumbach K. “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation.” Annals of Family Medicine. 2012.
Raffoul M, et al. “A Primary Care Panel Size of 2500 Is neither Accurate nor Reasonable.” Journal of the American Board of Family Medicine. 2016;29(4):496–499.
Neprash HT, et al. “Association of Primary Care Visit Length With Potentially Inappropriate Prescribing.” JAMA Health Forum. 2023.
Sinsky C, Colligan L, Li L, et al. “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.” Annals of Internal Medicine. 2016;165(11):753–760.
Arndt BG, et al. “Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations.” Annals of Family Medicine. 2017;15:419–426.
Casalino LP, et al. “US Physician Practices Spend More Than $15.4 Billion Annually to Report Quality Measures.” Health Affairs. March 2016.
Himmelstein DU, Campbell T, Woolhandler S. “Health Care Administrative Costs in the United States and Canada, 2017.” Annals of Internal Medicine. 2020;172(2):134–142.
Medscape Physician Burnout & Depression Report. 2024.
Han S, et al. “Estimating the Attributable Cost of Physician Burnout in the United States.” Annals of Internal Medicine. 2019.
MDVIP/Ipsos National Patient Frustration Survey. December 2023.
AMN Healthcare 2025 Survey of Physician Appointment Wait Times.
Busch B, Grzeskowiak J, Huth J. “Direct Primary Care: Evaluating a New Model of Delivery and Financing.” Society of Actuaries / Milliman. May 2020.
Klemes A, et al. “Personalized Preventive Care Leads to Significant Reductions in Hospital Utilization.” American Journal of Managed Care. 2012.
AAFP 2024 Direct Primary Care Data Brief. American Academy of Family Physicians.
Zhu JM, Marsh RH, Polsky D, Huntington M, Song Z. “Growth In Number Of Practices And Clinicians Participating In Concierge And Direct Primary Care, 2018–23.” Health Affairs. 2025;44(12):1473–1481.
DPC Patient Experience Survey. Medical Economics. 2025.
IRS Notice 2026-5 / H.R. 1 (One Big Beautiful Bill). Primary Care Enhancement Act. Effective January 1, 2026.
AAFP Position Paper: “Value-based Payment Models for Primary Care.” American Academy of Family Physicians.

Why I Left the Insurance Fee-for-Service Model of Primary Care