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Health care is expensive. A typical family in the United States spends $8,200 per year, or 11 percent of their $75,025 income, on health care—this includes everything from premiums to copays to federal and state taxes. This estimate does not account for the occasional surprise medical bill. If someone in the family has complex medical needs or a chronic condition, they would spend an even larger percentage of their household income on insurance.
In a time when health care costs are outpacing wage growth, members-only medical practices are becoming increasingly popular among middle- to high-income earners in D.C. Residents are spending more than 100 extra dollars per year on a primary care provider when they don’t necessarily have to.
One Medical Group, founded in 2007 and based in San Francisco, is one of the most popular membership-based primary care providers in large cities across the country, including in the District. As of September 2019, One Medical served approximately 397,000 members in nine markets in the United States, according to a filing for its initial public offering.
The District’s One Medical locations only serve adults, although its more established clinics in California and New York provide pediatric care. One Medical offers primary and general care, the kind a patient would seek for an annual physical exam or if they have flu-like symptoms. Outside of that, it offers routine gynecological (but not obstetric) care and can manage some mental health medications. If care is needed beyond its scope, One Medical refers patients out to an in-network specialist.
With an annual membership fee of $199, patients pay to skip the line, so to speak. They get same or next-day appointments that are expected to start on time; are seen immediately by a doctor—or whoever a patient is scheduled to see, be it a nurse practitioner or physician assistant—not a nurse; and gain access to 24/7 telemedicine services so they can videochat with a provider at any time. There’s also a mobile application that allows clients to book appointments, access medical records, and process billing. D.C. residents are opting to pay the membership fee on top of all their other medical expenses, the thinking goes, to access health care without the headaches.
“I have outsourced medical complexity to One Medical and they make it simple for me,” says 45-year-old Sharee Calverley Lawler, a stay-at-home mother of 6-year-old twins. She’s been going to One Medical for roughly five years.
Tolsun Waddle, 40, who works at a nonprofit focused on retirement and has been with the membership-based provider on and off since 2016, appreciates the speed One Medical provides. “There’s value to me in being able to see a doctor quickly.”
“We live in a country where health care is a product,” says Cielo Contreras, 37, who works at a children’s literacy nonprofit. She’s been a member with One Medical for three years. “So they are just providing a good product and a product I wanna buy.”
If they can afford the $199, these patients pay it. The quickness and quality is worth it, they say. Lawler, for example, switched her insurance to UnitedHealthcare when her previous one, CareFirst, stopped covering One Medical in 2018. It wasn’t clear if she is now paying more overall for her medical expenses by switching health plans, because what services each plan covers isn’t transparent enough to compare. But since she purchases her plan on DC Health Link based on the provider network, when One Medical was out, so was she. (CareFirst now covers One Medical again.) If she could take her kids to the One Medical clinic in Adams Morgan, where she lives, Lawler would, just to eliminate all the medical paperwork from her life. She thinks of the $199 as a convenience fee.
City Paper spoke with over a dozen residents who go to any one of the six One Medical locations, all in Northwest D.C. All but one enjoyed their experience thus far—an imperfect statistic but one that tracks One Medical’s 89 percent retention rate across its consumer members nationwide. These patients are relatively healthy and if they have a chronic illness that needs managing, they have a specialist for that. The overwhelming majority have jobs that paid decently and provided health insurance.
Many of these residents admitted to feeling funny about the membership fee at first. The idea of paying to be a member for something as basic as primary care sounded strange and unfamiliar. Some felt morally and ethically conflicted about it. The membership makes it exclusionary. One Medical clinics are concentrated in affluent neighborhoods and do not accept Medicaid. According to its website, the provider does accept “most” Medicare plans, but its public filing says it primarily serves the “working-age” and “commercially-insured population.”
Despite the conflicting feelings, patients’ past experiences with the health care system, the need to see a doctor fast without having to go to urgent care, or the lack of time and energy that’s needed to find a comparable provider outweighed concerns.
“I think that’s terrible, that health care is a product in our country,” says Contreras. “But that’s how it is.”
One Medical did not return City Paper’s repeated requests for comment.
In its S-1 filing, One Medical, a for-profit company, argues its “membership-based model supports ongoing and longitudinal relationships where we can serve as trusted advisors to our members and as partners to our enterprise clients.” The membership model, One Medical says, also generates revenue. Though it is not profitable yet, One Medical is valued at more than $1.5 billion, with private investors such as venture capital firm Benchmark and Alphabet.
The typical source of funding for primary care providers is insurance. But primary care providers across the country are embracing membership fees while rejecting insurance altogether because they are, in part, burnt out on working with insurance companies; the industry calls this “direct primary care.” Alternatively, One Medical also provides concierge care, accepting both insurance and membership fees, presumably enabling it to provide something extra. One Medical is more affordable as compared to other concierge providers. The average annual fee to become a member with the nation’s second-largest concierge management company, Concierge Choice Physicians, is between $1,500 to $2,400.
“Primary care is an area of health care that is ripe for disruption,” says Dan Mendelson, founder of the health care consulting firm Avalere Health. “Primary care physicians have not been paid well compared to specialists. They don’t have offices that reflect what is needed by consumers.”
Mendelson says a lot of providers are looking to disrupt primary care and One Medical is just one of many. What does set it apart is its “consistent branding.” Its neat and clean look. Find wide windows, trendy throw pillows, and a Humans of New York coffee table book in any clinic. One Medical signals modernity as soon as a patient walks in the doors.
“Like Tesla,” says Mendelson. “The question is what happens when the model is more fully deployed? They are still in building mode.”
It’s no secret that the country is unsatisfied with the health care system. This is why national lawmakers are looking to upend the status quo. In the meantime, if patients can pay to make the health care system work for them, they will.
Richard England, for one, is not leaving One Medical until the provider significantly jacks up its membership fee or other primary care providers catch up. He is extremely grateful for the care he and his wife have gotten so far, like when he had extreme food poisoning when he was in Spain and a nurse practitioner recommended anti-nausea medicine over the mobile application, or when his pregnant wife was in Germany and fell down some stairs and a nurse practitioner was able to reassure her by phone that she didn’t have any miscarriage symptoms.
“I’m blessed to call $200 a phenomenal price,” says England, 32, who works as an energy lobbyist. “It is worth the $200 dollars for me—in the grand scheme of things, especially in the health care system, and for someone who has the money to spend.”
One Medical attracts patients with the promise of ease. It’s not hard to book an appointment, even if a patient is new—which is not always the case. “If my average wait time was one week then I seriously doubt I would be going to One Medical,” says Waddle. The company sometimes waives the membership fee or insurance will cover the first year, making it easier to join the club at first. When Katie Crowe first joined in 2012, she asked One Medical to waive the fee the first year. She would not pay until she knew what she was buying. The company agreed to her terms. Crowe, 30, is still with One Medical because it’s convenient and the few times a year she does go to the clinic, the care is good. She budgets for One Medical the same way she does for her Amazon Prime account.
One Medical is one of hundreds of primary care providers in the District. A 2018 primary care needs assessment found there is actually an abundant overall supply of primary care providers relative to the D.C. population. There is one primary care provider for every 667 residents, according to DC Health. The supply, however, is not evenly distributed, with Wards 4 and 7 having relatively lower provider-to-population ratios. The report did not include data on wait times, but acknowledged one of the leading concerns from the providers interviewed were challenges around scheduling visits.
“The larger health centers certainly have infrastructure and intentions to create open access scheduling [or same-day scheduling] to make it easier for patients to get appointments more quickly,” says Dr. Anjali Talwalkar, the senior deputy director for the community health administration with DC Health. Talwalkar caveats that wait times vary depending on what patients are going in for and if they are new to the practice. “For new versus established patients, it’s something we see across the country where you always want to have a longer appointment time with new patients, obviously right, because you are getting to know somebody for the first time … so it can take a little bit longer [to book appointments],” she says.
Kate, who declined to use her last name over privacy concerns, waited three months to get an appointment with a primary care doctor with MedStar Health. She says it was the only provider in Northwest D.C. she could find that had a wait time of less than six months for new patients, at least with her plan. Two days before her appointment in May 2019, MedStar Health cancelled without rescheduling. When she complained about her experience with friends, they recommended One Medical.
“It’s hard finding a good person that insurance will cover,” says Kate, 33, who has a PPO plan with Aetna.
Kate got One Medical’s membership fee waived after applying for financial assistance online and showing proof of her student loans. Since joining One Medical, she says her relationship with preventative care has changed, in that she has one now.
Sam Peters, 29, decided to go to One Medical because it was the only provider where he could book an appointment within a month’s time. He purchased an HMO plan with CareFirst on DC Health Link for $315 per month. He has only been with One Medical since the summer, and whether he enrolls again depends on whether he can afford the membership fee next time around. Peters, who’s a bartender, just so happened to earn enough in tips when he paid the $199 fee. He will try to make it work because of how convenient it is with his working schedule. Easy booking jives with his odd, unpredictable hours.
Meera, alternatively, is no longer with One Medical. She was a member between 2015 and 2017 after a work colleague recommended the provider. She thought the membership fee was “weird” but her BlueCross BlueShield plan covered it for the first year so she figured “why not?” Looking back, Meera does not understand why One Medical has a membership fee.
“What is the point of paying extra? I don’t care if there is cucumber water in the lobby,” says Meera, who asked that City Paper omit her last name for privacy concerns.
She never experienced exceptional care. In fact, it was the opposite. It was Meera’s experience getting an intrauterine device inserted at One Medical that prompted her to leave. “They made it sound as innocuous as taking a vitamin,” says Meera. But her insertion was anything but. She couldn’t sit or stand after the insertion in October 2017, and ended up having her IUD removed elsewhere shortly thereafter because she did not trust One Medical to do it given the way they downplayed the initial procedure. Now, Meera, 27, is without a primary care doctor.
It is unlikely One Medical will start accepting Medicaid because the public insurance generally pays providers less than private insurers. This exclusionary practice doesn’t sit well with some One Medical members. At least that’s the case for Tanya Paperny, 33.
When she first enrolled roughly four years ago, Paperny had to consult her friends about it. It felt “icky” because the provider does not accept Medicaid. Paperny had Medicaid growing up in California, and is troubled that families like hers are not able to access a provider she now knows to provide quality care.
“As a person who grew up in a working class family, on food stamps and Medi-Cal … I don’t like the idea of there being tiers,” she says. “I’ve chosen to insulate myself from the problem in this way because my mental health is extremely important for me to maintain … if it doesn’t work, I’m not a functional person. It’s more important to me than opting out of a problematic system at this point in my life.”
Paperny never had a primary care doctor she saw regularly until now. Before her nonprofit job, when she was an adjunct professor and freelancer, she went to a Whitman-Walker clinic. She had no major complaints but says the higher volume of patients meant she was not getting “super individualized care.” Paperny never saw the same provider twice.
“I take for granted how different it is,” Paperny says, “Having had inconsistent and in some instances inadequate care for the first 30 years of my life to now be like having boutique care that I think is excellent and I know it’s good for me.”
“It breaks my heart that One Medical doesn’t take Medicaid,” says JoAnna Wendel, 29.
Wendel went to One Medical for a few years starting in 2016 and loved it. But then she lost her job over the summer and had to drop her provider when she enrolled in Medicaid. Wendel, who now works freelance as a science writer, just signed up for a Medicaid plan with Amerigroup. She applied for Medicaid in July 2019 but her insurance just kicked in in February due to technical difficulties.
Her experience trying to see a primary care provider as a Medicaid patient is quite different than when she had employer-based insurance. When she had flu-like symptoms recently, Wendel called Mary’s Center, the primary care provider she selected through Amerigroup. When the provider saw that she was a new patient, Mary’s Center requested she have a full physical exam before she could just drop in. The next available appointment, however, was a month away. So instead, she went to urgent care.
“I don’t want to blame Mary’s Center,” Wendel says. “There’s a lot of stuff I don’t understand.”
Now, Wendel has a hip flexor strain. She already has a physical therapist that she saw under her previous plan and who takes her Medicaid plan. But when she tried to schedule an appointment, her insurance required a doctor’s referral. Because her appointment for a physical with Mary’s Center isn’t until late March, she had to search for another doctor to give her a referral.
“American health care is really messed up,” says Wendel. “Living on Medicaid really made me realize that if you don’t have a traditional job, you are just not valued as a person.”