What we are already building, why it works, and what it will take to scale it
By Dr. Suzanne Gilberg
I want to tell you about a patient.
I will call her M. She is 48. She is an accomplished, disciplined professional in the prime of her career and someone who has navigated environments that required her to minimize and perform and push through - all qualities that served her professionally and cost her personally in ways she is only now beginning to understand.
For three years before she found her way to me, M. had been cycling through the conventional system. A primary care physician who had twelve minutes and a checklist. A gynecologist who was kind, rushed, and genuinely undertrained in menopause medicine. A psychiatrist who added an SSRI to the stack because the depression was real, even if its hormonal underpinning was not the primary diagnosis being discussed. Sleep medications because the insomnia was destroying her. Referrals for the joint pain and the cognitive fog that brought her to the edge of what she described as “I thought I was losing my mind.”
She was not losing her mind. She was in perimenopause. And nobody in the conventional system had the time, the training, or the structural incentive to connect those dots.
What changed for M. was not a new medication, though her treatment plan includes several. What changed was time. Sixty minutes at our first appointment. A complete history. The space to tell the whole story - not the seven-minute version - the actual version of what three years of undertreated perimenopause had done to her work, her relationships, her sense of herself. The treatment plan that followed was not complicated. It was thorough. It required someone to be in the room long enough to make it.
The medicine that changed M.’s life has existed for decades. What was new was the structure that made it possible to deliver it.
That structure is what this series - all five parts of it - has been building toward.
The model already exists. It is running. It is working.
I want to be precise here, because precision matters when you are making a claim against a $5.3 trillion system.
The membership medicine and direct primary care movement is not a boutique experiment. It is not a luxury indulgence for the wealthy few. It is a growing, data-supported proof of concept for what medicine looks like when the intermediary layer is removed and the clinician and patient are in the room together with enough time to actually practice it.
MDVIP, founded by two frustrated primary care docs in Florida in 2000, now has over 1,300 affiliated- not employed - physicians. They reported 90% patient retention as of December 2024, alongside 96% physician satisfaction. The same outcomes data that drove those retention numbers: 42% to 62% lower hospitalization rates and 20% to 24% fewer emergency room visits among MDVIP-affiliated patients versus matched controls.
Let’s try to understand those numbers again in the context of a system that spent $14,885 per person in 2024 and produced preventable deaths, undersupplied physicians, and a maternal mortality crisis. Against that backdrop, 42% to 62% lower hospitalization rates is not a consumer preference. It is a public health result. It is what medicine does when it has time to do its job.
According to the Employer Trends in Direct Primary Care 2025 report by Hint Health, 58% of all DPC memberships in 2024 were employer-sponsored. This is an 18% jump since 2022. 85% of employers stick with DPC a year after launching, and 70% are still engaged at two years. Case studies show employer groups with DPC spend roughly 52% less than comparable non-DPC cohorts.
This is not a trend. This is a market signal of the most direct kind: employers who are paying the costs of a broken system out of their own balance sheets are choosing to exit the insurance- based model at an accelerating rate. Not for philosophical reasons. Because it is less expensive to keep their employees healthy than to pay for the consequences of a system that keeps them sick.
The US concierge medicine market was valued at $7.35 billion in 2024 and is projected to grow at 10.33% per year through 2030. Approximately 12,000 concierge physicians practice in the United States as of 2024, up from roughly 150 in 2005. That is not a fringe. That is a movement.
And at MonarchMD, I am living inside it every day — not as a thought experiment but as a clinical reality. The membership medicine model for midlife women’s health is not a hypothetical about what care could look like. It is a daily demonstration of what care does look like when the structure finally matches the mission.
The equity argument and why it cannot be dismissed
I anticipate the objection and have heard it many times. It is derived from a genuine concern from people who care about the same things I do: if membership medicine serves primarily those who can pay for it, aren’t we just creating a two-tiered system? Aren’t we improving care for the already-advantaged while leaving everyone else behind?
It is a fair question.
First: yes. As currently structured, membership medicine disproportionately serves patients who can afford it. The existence of a proof of concept does not solve the access problem. A model that works for some people is not the same as a model that serves all people.
But here is what the objection misses: the alternative is not an equitable system. And before we call membership medicine a luxury, let’s talk about what the current system actually costs the people it claims to serve.
For employed Americans with employer-sponsored coverage, the average worker’s share of premiums plus deductible runs approximately $3,378 per year for single coverage and $9,000–$10,000 for a family. And that is the protected tier - the one where an employer absorbs the majority of the premium. For self-employed women between 40 and 60 - the exact demographic most likely to be navigating perimenopause and menopause without adequate clinical support - the math is entirely different. The average unsubsidized marketplace premium for a 50-year-old woman is now $1,052 per month. At 54, it tops $1,250 per month. Before she has seen a single physician or filled a single prescription. Add the average marketplace deductible of $2,789, and a self-employed woman in midlife is spending well over $15,000 per year for access to a system that gives her physician twelve minutes to see her. For a family, unsubsidized marketplace premiums can reach $2,000 to $3,500 per month or $24,000 to $42,000 annually. And those enhanced subsidies that softened that number for millions of Americans? They expired December 31, 2025.
You read that right! A self-employed woman in midlife is paying up to $42,000 a year for a system that makes her wait 70 days for an appointment, gives her physician 12 minutes to see her, has no dedicated reimbursement infrastructure for the health transition she is currently living through, and produces worse outcomes than virtually every comparable nation on earth. And when she considers a membership medicine model that gives her same-day access, a physician with time, and a longitudinal care plan built around her body and her decade we call that the luxury option.
The luxury is not the membership. The luxury is being able to afford to stay in a system this broken and still receive adequate care. Most women cannot.
So when someone tells you that membership medicine is elitist ask them to do that math again.
The choice is not between a perfect equitable system and an imperfect membership model. The choice is between a model that is proving what is possible and a model that is producing what we have.
The goal is not to defend membership medicine as the final answer. The goal is to use it as the proof of concept that it is, to demonstrate what relationship-based, prevention-centered, time-sufficient care produces in outcomes, in physician satisfaction, in patient retention, in cost, and then to demand the structural conditions that make it accessible to everyone. Value-based payment reform. Reimbursement models that reward longitudinal care and preventive interventions rather than procedure codes billed per hour. Policies that make the direct care model viable at community health center scale, not just in private membership practices.
37 states introduced legislation focused on health equity in 2025 alone. The state-level momentum is real. What is missing is the willingness to connect that demand to the models that are already producing the outcomes we claim to want.
The human right argument and why I am done being diplomatic about it
Health is not a commodity. Access to competent, time-sufficient, relationship-based care is a human right. It is not a market preference, a consumer choice nor a benefit earned through employment or premium payment. A right. Full stop.
This position is radical only in the context of American health policy, where the market framework is so deeply entrenched that the phrase “healthcare is a human right” is treated as partisan rather than axiomatic.
Universal health care could have saved an estimated 212,000 lives in 2020 alone. That is the body count of a choice made deliberately, sustained stubbornly, and paid for by the people this system was least designed to protect.
But the coverage debate alone is not enough and this series has been making that argument from the beginning. The fight for the right to health is not only a fight for insurance cards. It is a fight for the structural conditions that make coverage meaningful. The right to health means the right to a physician who has time to be a physician. A treatment plan built for your body, your history, your specific needs - not for the billing code that fits plugged into a protocol driven algorithm. A healthcare system whose financial architecture is oriented toward keeping you well rather than processing your illness efficiently.
That is what we are fighting for. And it will require fighting on every front simultaneously: coverage, reimbursement, training, time, relationship, and the sustained political will to stop protecting a system that has failed the people it was built to serve.
What the practitioners who left are building
Let’s return to the physicians who left - because this series began by defending them and I want to end by honoring them more specifically.
They are an extraordinarily diverse group of clinicians who reached a common conclusion through different paths: that the system as designed was incompatible with the medicine they were trained to practice, and that the only way to continue practicing that medicine was to build something different. They are not, as the narrative sometimes implies, a monolithic group of affluent physicians pursuing lifestyle medicine for wealthy patients.
Some built solo direct primary care practices serving working-class communities on subscription models that cost less per month than most people spend on streaming services. Some built multi-specialty membership practices that serve midlife women specifically because they recognized that this population is uniquely underserved, uniquely motivated, and uniquely able to drive the adoption of models that can then be scaled. Some, like the physician-focussed team at MonarchMD, are building the infrastructure that makes the membership medicine model replicable, sustainable, and clinician-centered in ways that hospital employment structurally cannot be.
When 83% growth happens in five years in the concierge and membership medicine space, that is not a boutique trend. That is a market signal. The physicians who built it are not abandoning the mission of medicine. They are practicing it. In conditions that make it possible. And they are proving, with outcomes data, that the conditions matter as much as the training.
The revolution is not being designed in a committee. It is being built by practitioners who refused to deliver care in the conditions the system provided, and by patients who refused to accept that those conditions were inevitable.
A final word to those reading this
You have been patient for a very long time. Patient in waiting rooms. Patient with systems that dismissed your symptoms. Patient with physicians who meant well and were given mere minutes and a template. Patient with a healthcare conversation that has focused on your needs without addressing the structural reasons those needs go unmet.
I am asking you to be done with patient.
Although cynicism would not be inappropriate, it is the thing that makes you stop believing change is possible so that you stop demanding it. So be done with being patient in the specific sense of accepting inadequacy as inevitable.
This generation of midlife women broke open the menopause conversation. We insisted our symptoms were real when the culture told us they were trivial. You built communities, read the research, found the physicians, demanded the treatment, and changed the public narrative around a biological experience that had been medicalized, minimized, and mystified for generations.
We have the tools, the voice and the numbers. We have the specific, documented, evidence-based knowledge that the system as designed is producing the outcomes it is producing not because of medical limitations but because of structural choices that can be changed.
The bill that no one wants to pay is not inevitable. The most expensive failure in the world is not a fixed feature of reality. The revolution that is already underway is being built by practitioners who chose the mission over the machine, and by patients who refused to accept that seven minutes was all they were worth. It is a proof of concept, growing at 10% per year, carried by data that the conventional system cannot refute.
We don’t need permission to build what works.We need each other. We need to be loud.And we need to be willing to say, in every room we enter:This is not enough. And we are not waiting any longer.
Dr. Suzanne Gilberg is a board-certified OB/GYN, integrative medicine physician, Chief Clinical Officer at MonarchMD, and founder of the Menopause Boot Camp. She is the author of Menopause Bootcamp and the forthcoming Plant Medicine: A Modern, Science-Based Guide to Ancient Wisdom, Medicinal Herbs, and Healing Plants. Find her at @askdrsuzanne and @themenopausebootcamp
Selected references:
KFF 2025 Employer Health Benefits Survey — for employed figures
ValuePenguin 2026 Average Health Insurance Rates by Age — for the age-based premium data ($1,052 at 50, $1,250+ at 54)
Peterson-KFF Health System Tracker — for the $2,789 average ACA marketplace deductible
GrayGroupIntl.com / ObamaCareSolutions.com — for the enhanced subsidy expiration and its impact on self-employed
Budget Seniors / KFF — for family marketplace premium range
The current healthcare model doesn't work for most, but especially not for women going through perimenopause that first need to be seen and heard before addressing their multiple symptoms and layered treatment plans. Thank you for shedding light on this issue but more importantly always pointing to some solutions. Even if its just a shift in mindset and expectation.