When Maya\u00a0Mackrandilal opened up an email from her primary care physician in 2021, she laughed. She had recently switched to the practice, and the letter informed her that, starting in just a few months, it would institute a fee of $250 per year, in addition to whatever she paid for insurance. Her husband also saw that doctor, so as a family, it would cost them $500 more each year.\u00a0<\/p>\n
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\u201cI thought, \u2018There is no way I am paying this money,\u2019\u201d she said.\u00a0<\/p>\n
Mackrandilal decided to find a new physician in Los Angeles who didn\u2019t charge a fee, an arduous process that she ultimately decided was worth it, because she said she likes her new physician better. Still, the experience made her wary and on edge, waiting for the next fee to drop. Her child\u2019s pediatrician doesn\u2019t charge one yet, but she\u2019s heard many do, and she said they\u2019d change doctors if it happened.\u00a0<\/p>\n
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These annual fees are becoming more common among health care providers in California\u2019s major metros. There isn\u2019t a standard for what these fees cover, let alone what they cost, creating a new \u201cwild west\u201d that many patients don\u2019t even realize exists until after they\u2019ve scheduled an appointment. For some, a few hundred dollars every year may be a nominal amount to pay for access to quality health care, but for others, it\u2019s widening the disparity in an already fragmented and costly medical system.\u00a0<\/p>\n
Reinventing the system<\/p>\n
Hybrid primary care \u2014 the combination of traditional insurance-based billing and a membership fee \u2014 has been around for nearly two decades. When it debuted, an emphasis on a high-touch, tech-focused approach to preventive medicine seemed revolutionary, for those who could afford it. Gone were the days of struggling to get in to see a doctor when an ailment arrived; instead, members could get a same-day appointment, often using digital technology in a new way.\u00a0<\/p>\n
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<\/p>\n Add Preferred Source<\/p>\n <\/a><\/p>\n The most well-known pioneer in the space, San Francisco-founded One Medical, opened up in 2007. Membership started at $100 a year and often came fully covered by big tech companies, helping supercharge its rapid expansion. Ultimately, Amazon acquired One Medical in 2023. Today, it has around 240 offices across the U.S. and more than 800,000 members, as of 2022.\u00a0\u00a0<\/p>\n Article continues below this ad<\/p>\n FILE: Street-level view of a One Medical facility in the Mission District of San Francisco on Sept. 11, 2025.<\/p>\n Smith Collection\/Gado\/Getty Images<\/p>\n Since then, many copycats have emerged, especially in California, including biometrics-focused Forward and women\u2019s health-focused companies like Tia. But now, more traditional practices are adopting the model, instituting their own annual fees, frequently stating they need them to stay afloat. Doctors cite a number of reasons for why this additional revenue is necessary, most often noting increasingly low insurance reimbursements, the need for more administrative staff to run a practice and overall physician burnout.\u00a0<\/p>\n And it\u2019s not just hybrid primary care that\u2019s increasing in popularity. Concierge medicine \u2014 which typically commands a higher annual fee \u2014 is also on the rise. Some medical practices are choosing to opt out of insurance altogether, offering their services for cash instead, often promising enhanced or \u201cluxury\u201d health care. In a\u00a0study<\/a> that looked at the number of direct primary care and concierge practices from 2018 to 2023, the number grew by 83.1%, from 1,658 practices to 3,036, the analysis from Johns Hopkins, Oregon Health & Science University, and Harvard Medical School found.<\/p>\n These providers can have memberships ranging from $1,000 to as much as $20,000 or more a year, which may include some, but rarely all, services. And some still recommend having insurance.\u00a0<\/p>\n Article continues below this ad<\/p>\n \u201cThe growth of these models may benefit participating patients and clinicians, but it\u2019s important everyone understands the potential impact these practices have on the health care system at large,\u201d Dan Polsky, co-author of the study, told Johns Hopkins<\/a>. \u201cWe have to consider how the growth of these models may affect access to primary care for the vast majority who can only afford the care covered by their insurance plan.\u201d<\/p>\n \u2018Can\u2019t keep your doors open without it\u2019<\/p>\n Dr. Sarah Yamaguchi, a gynecologist in Los Angeles, started charging what she calls an administrative fee in July 2025. For her, the pressures had been mounting for years, as insurance reimbursements cratered, her rent kept rising and she was dedicated to paying her employees fairly.\u00a0<\/p>\n Yamaguchi tried fitting in more patients when her insurance reimbursements went down, but she soon found herself \u201crunning around like a crazy person,\u201d she said, and not enjoying her work. Meanwhile, as insurance plans have gotten more complicated and numerous over the years, it has required more staff to facilitate prior authorizations and reimbursements. She said she sees around 2,500 patients per year, and even if each patient visit requires an extra five minutes from the staff to coordinate insurance needs, something they can\u2019t bill for, she estimates that\u2019s an extra 208 hours of work a year.\u00a0<\/p>\n Article continues below this ad<\/p>\n Yamaguchi decided her options were either to drop insurance altogether \u2014 which would mean she could eliminate several employees\u2019 positions \u2014 or give up on many of the amenities that were crucial to her practice, like having a patient portal and reasonable response times to electronic messaging. She ran the numbers, and ultimately, when she looked at pricing without insurance, \u201cI felt like I was blackmailing my patients,\u201d she said, since for healthy young patients, payments seemed reasonable, but if something went wrong, it would be astronomical.<\/p>\n FILE: People walk outside Good Samaritan Hospital in downtown Los Angeles on Thursday, April 21, 2016.<\/p>\n Nick Ut\/AP<\/p>\n She had considered opting out of insurance before but finally decided she\u2019d \u201chave way too much guilt\u201d if she did that. \u201cI like my patients too much, so I need to take insurance,\u201d Yamaguchi said.\u00a0<\/p>\n She settled on $250 per year, which would cover messaging her via the patient portal without an appointment and include filling out any needed paperwork. \u201cIf I wanted to do it to be a millionaire, I would not be doing $250 a year \u2026 If I wanted to make money, I would just drop all insurance, but I don\u2019t want to do that to my patients,\u201d Yamaguchi said.<\/p>\n Article continues below this ad<\/p>\n She said she tried to keep that number as low as possible, knowing she\u2019d likely lose some patients over it. Yamaguchi said she actually got less blowback than she thought when she sent out a letter informing patients of the change. She was even surprised by how many patients messaged her supportively, saying they\u2019re happy to pay it for the care they receive. She said she believes more people are becoming aware of the problems with the health care system.\u00a0<\/p>\n \u201cThey\u2019re becoming more common, because if you\u2019re not a large group, you can\u2019t keep your doors open without it,\u201d Yamaguchi said.\u00a0<\/p>\n The rise of telehealth<\/p>\n Demands on doctors have also rapidly changed in the past decade. Once only accessible on the phone, the COVID-19 pandemic supercharged the adoption of telehealth, and digital advances made messaging a doctor easy. But with those advances came expectations that a doctor would answer inquiries in a timely and thorough manner, something that\u2019s not necessarily covered by insurance.\u00a0<\/p>\n Article continues below this ad<\/p>\n Both Medicare and private health insurers have adopted new rules since around 2019 to accommodate the increase in telehealth, allowing for a range of billing for these types of \u201cappointments.\u201d But one study found that messages increased 157%<\/a> from a pre-pandemic average, and assessing what counts as a \u201cvisit\u201d can be nebulous.<\/p>\n FILE: Dr.\u00a0Nilesh Shah, who is at the VA Sorrento Valley Clinic, works with patient Neil Harrington, who is up in north county, on Jan. 17, 2020, in San Diego.<\/p>\n The San Diego Union-Tribune\/Getty Images <\/p>\n<\/p>\n
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