As reimbursement challenges and administrative burdens continue to squeeze physicians, cash-only and direct primary care models are gaining ground.
The growth data backs that up: From 2018 to 2023, the number of direct primary care and concierge practice sites grew by 83.1%, and the number of clinicians participating in them by 78.4%, according to a 2025 article in Health Affairs.
Medical school debt, burdensome paperwork and declining reimbursements are the primary factors driving physician interest, and ASCs are increasingly exploring the same path as insurance reimbursement becomes harder to secure.
When insurance can’t keep up with medicine
Insurers’ inability to keep pace with rapid advances in biologics, diagnostics and AI-enabled care is pushing more physicians, and patients, toward cash-pay options.
“Insurance companies lag behind the science and speed at which medicine advances,” said Joshua Siegel, MD, director of orthopedic sports medicine at Access Sports Medicine and Orthopaedics in Exeter, N.H., told Becker’s.
He pointed to the growth of functional medicine and advanced diagnostics, including programs such as Galleri, that have expanded while insurers “sort out if and how to respond or pay.”
The pattern is a familiar one: New services launch as cash-pay, build clinical momentum and patient demand, then eventually get evaluated for broader coverage. Dr. Siegel has watched this play out over the past decade with treatments like Class IV laser therapy and extracorporeal pulse activation technology.
AI is also reshaping how patients navigate these choices.
“AI tools allow patients to be their own advocates and search for doctors who will provide what they want,” he said. “The days of providing a limited scope of services and not informing patients of their many choices are over.”
A growing niche: Dental anesthesia
Dental sedation is emerging as a meaningful cash-pay opportunity, particularly for certified registered nurse anesthetists. The primary driver is baby boomers who want full-mouth implant work completed in a single day under sedation rather than across multiple appointments.
“I’ve got a dental contract right now where we offer an à la carte sedation menu — sedation for a cleaning, an extraction, implants — all cash, because most insurance doesn’t cover it,” said Jeff Tieder, MSN, CRNA, clinical assistant professor at the University of Tennessee at Chattanooga. “The dentist gets more done per day, the patient has a better experience and it’s a meaningful revenue stream.”
Investor interest is following. Private equity firm Havencrest Capital Management recently completed a majority recapitalization of OFFOR Health, an Ohio-based provider that integrates anesthesia teams directly into dental practices.
Direct primary care
Direct primary care is one of the most-discussed models for independent practice in 2025, but for many physicians, the definition remains fuzzy.
In a typical DPC arrangement, patients pay a monthly fee for comprehensive preventive care and direct physician access. According to a 2024 data brief from the American Academy of Family Physicians, monthly DPC membership fees range from $20 to $49 for children and $50 to $100 for adults ages 65 and younger. Some practices operate fully outside insurance; others still run labs and imaging through coverage. Patients typically get unlimited appointments and longer visits, but they may need separate insurance for specialty or emergency services.
Concierge medicine, often conflated with DPC, skews higher end: annual fees that averaged $1,500-$1,700 in 2014 have risen to $2,000-$5,000 today, with some practices charging upward of $20,000 annually, according to a report from PrimaryMD. For physicians, the appeal is control. DPC allows greater flexibility in determining treatment, freed from the constraints of fee-for-service billing.
The regulatory patchwork
The legal landscape for DPC remains uneven, and that’s a real operational risk for physicians considering the model. The core concern at the state level is whether DPC membership fees constitute insurance, which would subject practices to an entirely different regulatory framework. In approximately half of states, laws explicitly exempt DPC arrangements from insurance regulation, though these laws often apply to a narrow scope of arrangements and require providers to build specific patient protections into their contracts.
On the federal side, a significant barrier was recently removed. The One Big Beautiful Bill Act, which took effect Dec. 31, eliminated the disqualification issue for individuals contributing to an HSA while participating in a DPC arrangement. This means patients can now use pre-tax HSA funds to pay DPC membership fees. Previously, enrolling in a DPC practice could disqualify a patient from contributing to an HSA entirely, a meaningful deterrent for cost-conscious consumers.
Who gets left out
Cash-pay and DPC models have a well-documented equity problem: They work best for patients who can afford them.
The subscription structure, while often more affordable than traditional insurance premiums for healthy individuals, creates barriers for lower-income patients, the uninsured and those with complex or chronic conditions who require more than primary care. DPC practices are predominantly concentrated in urban and developed regions, leaving rural populations underserved, according to research from Straits.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.