Hawaii residents facing a shortage of primary care doctors are increasingly turning to direct primary care practices, which do not bill through health insurance and instead charge patients flat monthly membership fees. For some, the appeal is speed and access: Kiah Bland, a Waikiki resident, said she searched for a primary care physician last month and found that most doctors in her area were not accepting new patients or had long waits for office visits. She eventually found a Honolulu doctor who could see her immediately for $200 a month after explaining that he does not accept health insurance, and Bland said she decided to buy the membership following a free consultation.
Bland said the doctor addressed her health concerns in depth and without haste, and she described the outcome as a relief after weeks of searching. She said the monthly fee allowed her to sidestep health insurance while still establishing a primary care relationship. Her experience reflects what the story describes as a small but growing number of Hawaii patients choosing direct primary care, a model that relies on patient memberships rather than insurance company reimbursement.
Doctors who endorse direct primary care say the structure gives them more predictable income and removes time-consuming insurance billing and overhead, which they say helps them spend more time with complicated patients. The model can also allow some issues to be handled by phone or text message, according to the report. A 2024 study by the American Academy of Family Physicians, as cited in the report, found that 99% of direct primary care practices provide same-day appointments.
But the switch carries trade-offs that could matter for a state already stretched by workforce gaps. The report quotes Dr. T. Scott McMurry, who opened a direct primary care practice in Kona in 2023, saying the practice exists because doctors lost relationship-centered care and that insurance turned them into “machines conducting 8- to 15-minute patient visits.” He described direct primary care as removing a “middle man of insurance” that he said created barriers for doctors and patients.
Researchers and physicians also highlight how panel size differs under the membership model. The report says direct primary care practices typically see far fewer patients—about 400 on average—compared with traditional primary care practices, where primary care doctors see between 2,300 and 2,900 patients. Kelley Withy, a physician and researcher at the University of Hawaiʻi’s John A. Burns School of Medicine, said she supported the idea if it improved care and doctors’ lives but warned she was “concerned that we might be needing a lot more doctors.”
The state’s need for additional physicians is part of the debate. The report says Hawaii has 12,688 licensed physicians but just over 3,000 are full-time active, and that researchers at the UH medical school estimate the state needs another 833 doctors, including 178 primary care physicians, to meet patient demand. Against that backdrop, Dr. Curtis Takemoto-Gentile, who converted his Honolulu practice to direct primary care on Jan. 1, represents both potential help and potential worry, the report said.
Takemoto-Gentile described burnout in traditional, insurance-based medicine and said he nearly closed his practice before shifting models. He said the move prevented retirement that would have left about 2,500 former patients scrambling for new physicians, but he also said downsizing his patient load to 300 has meant many of those patients now seek a new doctor. The report says handling fewer patients has given him time and flexibility to offer home visits to seniors, homebound patients, or people with limited mobility.
The report also describes direct primary care’s limited footprint in Hawaii. It says there are seven direct primary care practices in the state across O‘ahu, Kaua‘i and the Big Island, with three Honolulu physicians adopting the model in the last five months. It adds that the model originated on the U.S. mainland in the late 1990s but did not appear in Hawaii until 2016. Dr. Donna Mayeda, a 38-year-old physician who moved to O‘ahu last year to establish a direct primary care practice, said she could see herself in the model “until I retire,” after describing how she had been questioning how much longer she could continue in the traditional system.
Mayeda, who is described as a mother of three, said she also considered a career in medical consulting before deciding to step outside of insurance-based care. She said her patients include public school teachers, single-income families, first responders, self-employed business owners and venture capitalists, and she said her goal is to offer adjusted rates for lower-income patients. On Kaua‘i, the report says Dr. Clara Krebs operates the island’s only direct primary care practice and charges a monthly rate between $250 and $350, citing high commercial real estate costs.
Krebs told the report that her practice limits patients to about 200 and that another 250 people are on a waitlist. She said her highest fees in the state have not deterred patients, and quoted a belief that people want “to pay to not be in a Taco Bell drive-thru of medicine.” The report says Krebs plans to double her patient base this summer by adding a second physician from San Francisco, with that doctor expected to charge a lower membership fee.
Patients described in the report said the membership model can feel more predictable than insurance billing and can bring their doctor within reach. Maureen Harnisch, in her 60s and living in Kaimuki, said she pays $200 monthly to her doctor of 17 years after he stopped accepting her insurance in January. She told the report she canceled other subscriptions—an identity theft protection service and TV and movie streaming services—to make room for the membership fee, adding, “life is about choices,” and saying she believes her doctor is “a superior doctor.”
Rachel Hughes, a 42-year-old mother of two in Kona, said she previously felt like she was “just a number” in the insurance-based system before joining a direct primary care practice. Hughes said she values fast access and the fact that her doctor knows her by name and takes time to learn about her family health history and lifestyle. She also described how, when she sought help with intense, chronic headaches, her doctor performed multiple interventions during a single, lengthy appointment rather than simply prescribing medication.
The report says changes in federal tax rules adopted this year now allow patients to use pre-tax funds from a health savings account to pay for direct primary care fees that do not exceed $150 per individual or $300 for a family. It also describes how a coverage mismatch can occur even when many residents have health insurance: in practice, people may wait weeks or months to get an appointment, and that delay can push them toward urgent care or emergency departments. The report says Hawaii’s rural geography, cost of living and low reimbursement rates from insurers can worsen access, and it cites Medicaid reimbursement rates as sometimes barely covering the cost of care.
The story also includes doctors’ accounts of why insurance can narrow what primary care visits allow. It quotes Takemoto-Gentile describing a financial disincentive in traditional insurance-based care, saying that insurance reimbursed physicians with a flat office visit fee regardless of how long the visit lasted or how many procedures were performed. After converting to direct primary care, he said he now sees 4 to 10 patients a day instead of 20 to 25.
“I think of it like a gym membership,” Hughes said, describing a membership she says brings peace of mind because everything is covered and the doctor is reachable by text. The report also includes quotes from other doctors describing what they say they gain from membership-based models: more personalized care, improved work-life balance, and time for practices that can support seniors and people with limited mobility.