Bringing In a Second Provider: How a Membership Practice Grows Without Losing Its Soul

Yoon Hang Kim, MD, MPH

Board-Certified in Preventive Medicine | Integrative & Functional Medicine Physician

Every membership-based practice that succeeds eventually faces the same question, and it arrives sooner than expected: what happens when you are full?

A capped membership model is a promise. When a practice limits itself to a defined number of active clients, it promises each of them time, attention, and access that the conventional system cannot deliver. But a cap also creates a ceiling — on the number of people the practice can serve, and on the practice itself. When the waiting list grows and the calendar fills, the founder must decide: stay small forever, or bring in a second provider and grow deliberately.

I have been living inside this question, and I have spent considerable time learning from physician colleagues around the country who have already made the leap. What follows is what I have learned — the models that work, the mistakes that recur, and the framework I believe serves both the practice and the provider who joins it.

The Two Classic Models — and the Debate Between Them

Talk to enough independent practice owners and you will find that nearly every arrangement reduces to one of two philosophies. National data confirm the spectrum: the American Academy of Family Physicians reports that family physicians working in direct primary care settings earned an average full-time income of roughly $289,000 in 2024, delivered through varying blends of base salary, bonus or incentive, and practice revenue share [1]. The blend is precisely where the debate lives.

The first philosophy is the salary and shared-pool model. The new provider is paid a straight salary, and clients belong to the practice as a whole rather than to any individual clinician. Clients schedule with whichever provider they prefer, or take the first available appointment for acute concerns. Practices that have run this model for many years describe it as easy and clean for both sides. One provider covers messages and calls for a week at a time, giving colleagues genuine time away — a luxury solo physicians rarely experience. Proponents argue that tying compensation to individual client panels creates a quiet wedge between employer and employee: coverage becomes a favor rather than a duty, vacations become negotiations, and a departing provider can walk away with a panel that took years to build. The caution worth noting: analysts who studied the straight-salary hiring wave of the 1990s found that guaranteed pay with no growth linkage sometimes eroded productivity [2]. Membership medicine softens that risk — revenue flows from relationships and retention rather than visit volume — but it does not eliminate the need for some link between contribution and reward.

The second philosophy is the percentage-split model, in which each provider maintains their own panel and receives a defined share — commonly 60 percent to the provider, 40 percent to the practice — of the membership revenue that panel generates. Practices in their tenth year of this arrangement describe it working beautifully. Their argument is equally compelling: clients love having one clinician who knows them deeply, providers love the direct connection between effort and income, and a reasonable restrictive covenant addresses the departure risk. Ownership of a panel, they argue, is not a wedge; it is accountability. The trade-off is well documented in the compensation literature: production-based pay holds each clinician accountable, but it can discourage the sharing of clients and the collaborative coverage that small practices depend on [3].

Both camps are right — for their practices. The honest answer is that the model must fit the practice, not the other way around.

Why a High-Touch Integrative Practice Is Different

Most of the practices in this debate are primary care practices with hundreds or thousands of clients paying modest monthly fees — typical direct primary care memberships run $50 to $100 per month [1]. A membership-based integrative and functional medicine practice operates on different physics. The panel is smaller by design. The monthly fee is higher because the visits are longer and the medicine is deeper. And — this is the crucial part — clients often join because of the founding physician's specific expertise in areas such as low dose naltrexone, mast cell activation syndrome, autoimmune conditions, or integrative oncology.

That reality changes the arithmetic of adding a provider in three ways.

First, the shared pool cannot be assumed. In a large primary care practice, clients happily see “first available.” In a small practice built on complex chronic illness, the therapeutic relationship is the product. A second provider must earn trust; it cannot be assigned.

Second, a pure percentage split punishes the newcomer. A provider who starts with zero clients and is paid purely on percentage earns almost nothing for months. Even in conventional groups, compensation experts note that incentive pay is typically of modest potential in the first year or two, when most practices hope simply to break even on a new hire [4]. In a small membership practice, that ramp is slower still. An arrangement that ignores it attracts no one worth hiring — or worse, attracts someone good and then loses them.

Third, the hire should expand the mission, not divide it. If a practice is capped at a given number of clients, the right question is not “how do we split the existing membership?” but “how many additional people can we now serve?” Dr. Paul Thomas, who grew Plum Health DPC in Detroit from a solo practice to a multi-physician group, put it plainly: he did not hire a second doctor to make more money, but to build a more sustainable practice — one in which the community, the joining physicians, and the practice itself all come out ahead [5]. Done correctly, the second provider is the reason a practice capped at 99 clients can responsibly grow toward 199 — doubling the number of people who receive this kind of care without diluting it for anyone.

Physician or Non-Physician Provider?

The same framework applies whether the second provider is a physician, a nurse practitioner, or a physician assistant — but the details shift. A nurse practitioner or physician assistant typically carries a lower compensation cost and can excel at follow-up visits, titration appointments, and protocol-driven care, making the guaranteed-compensation stage easier to fund. But two additional considerations enter. Clinically, complex integrative cases still require physician-level oversight, and the supervision or delegation arrangements that make this lawful vary meaningfully by state. Financially, that oversight is real work: the AAFP's position is that physician supervision of NPs and PAs deserves defined compensation in its own right, structured according to the time and effort involved, the experience of the clinician being supervised, and whether panels are individual or shared [6]. A practice that hires a non-physician provider without budgeting for the supervising physician's time has simply hidden a cost, not avoided one.

A Framework That Honors Both Sides

Synthesizing the experience of colleagues with the realities of a high-touch model, I believe the fairest structure is staged — it changes as the provider's practice within the practice matures.

Stage one: guaranteed compensation while the panel builds. In the first year, the new provider is paid a guaranteed hourly rate or salary, regardless of panel size. This removes financial fear, allows the provider to learn the practice's clinical philosophy without pressure, and gives both parties a genuine working audition. During this stage the provider serves the whole practice — follow-up visits, titration appointments, new client onboarding — while building relationships naturally. Compensation analysts describe this same architecture as “base salary plus” models: a guarantee that protects the newcomer, often time-limited, layered with rewards that begin once defined thresholds are met [3].

Stage two: a graduated revenue share that rewards growth. Once the provider's panel can support it, compensation transitions to a tiered percentage of the revenue they generate — a modest split at lower revenue levels that becomes progressively more generous as the panel grows. The logic is simple and, I believe, deeply fair: the practice carries the risk, infrastructure, and marketing burden during the vulnerable early period, so it retains a larger share early. The provider's effort drives growth in the later period, so the provider keeps a larger share of every additional dollar as the panel matures. The incentive gradient points exactly where it should — toward growth, retention, and excellent care.

Guardrails matter as much as percentages. Whatever the numbers, several protections belong in every agreement, and the AAFP's guidance on physician employment contracts is a useful checklist for both sides: a clearly understood compensation formula, mutual without-cause termination with a defined notice period, and restrictive covenants that are reasonable in duration, geography, and scope [7]. To these I would add two provisions specific to membership medicine: a clearly defined transition trigger, so the switch from guarantee to percentage always feels like a raise and never a cliff; and compensated cross-coverage, so covering a colleague's clients is respected work rather than a resented favor. Sample employment agreements and contract-review guides specific to direct-care practices are freely catalogued at DPC Frontier for any physician beginning this process [8] — and no owner or candidate should sign without independent legal review.

The Question Beneath the Question

Compensation models are ultimately about values. A practice built on short-term profit will structure its hires to extract maximum margin — and will spend the next decade recruiting replacements. A practice built on vision and sustainability will structure its hires so that the provider, the practice, and above all the clients each receive a genuinely good deal — and will spend the next decade growing.

One colleague who recently added a physician to her practice put it in a way that has stayed with me: her goal was not to earn more from the hire, but to bring another like-minded physician into her community — and to make sure everyone involved felt they got a great deal. That is the spirit in which growth should happen.

My own practice, www.directintegrativecare.com, was founded on the conviction that medicine works best when a physician has the time to think, listen, and treat root causes rather than symptoms. Growth, when it comes, must serve that conviction. Adding a second provider is not a departure from a capped membership model — it is the only honest way to extend its promise to more of the people who need it.

Disclaimer: This article is for educational and informational purposes only. It does not constitute legal, financial, tax, or business advice, and it is not medical advice. Practice structures, compensation arrangements, supervision requirements, and restrictive covenants are governed by state and federal law and vary by jurisdiction. Consult a qualified attorney, accountant, and other appropriate professionals before making decisions regarding practice structure, hiring, or compensation.

References

1. American Academy of Family Physicians. Direct Primary Care Model for Family Physicians. AAFP Practice & Career Resources. https://www.aafp.org/family-physician/practice-and-career/delivery-payment-models/direct-primary-care.html. Accessed August 1, 2026.

2. HSG Advisors. Physician Compensation Models. https://hsgadvisors.com/articles/physician-compensation-models/. Accessed August 1, 2026.

3. Withum. Physician Compensation Series: Compensation Models. https://www.withum.com/resources/physician-compensation-series-compensation-models/. Accessed August 1, 2026.

4. NEJM CareerCenter. Physician Compensation Models: The Basics, the Pros, and the Cons. https://resources.nejmcareercenter.org/article/physician-compensation-models-the-basics-the-pros-and-the-cons/. Accessed August 1, 2026.

5. Thomas P. How to Hire a Second Doctor for Your Direct Primary Care Practice. Startup DPC Blog, December 12, 2020. https://www.startupdpc.com/blog/2020/12/12/how-to-hire-a-second-doctor-for-your-direct-primary-care-practice. Accessed August 1, 2026.

6. American Academy of Family Physicians. Physician Compensation for Nurse Practitioner and Physician Assistant Oversight (Policy). https://www.aafp.org/about/policies/all/physician-compensation-oversight.html. Accessed August 1, 2026.

7. American Academy of Family Physicians. Navigating Physician Employment Contracts. FPM. September/October 2021. https://www.aafp.org/pubs/fpm/issues/2021/0900/p17.html. Accessed August 1, 2026.

8. DPC Frontier. Forms: Physician Employment Agreements and Contract Resources. https://www.dpcfrontier.com/forms. Accessed August 1, 2026.

About Dr. Kim

Dr. Yoon Hang “John” Kim is a board-certified physician with more than 20 years of experience in integrative medicine. He completed his fellowship at the University of Arizona under Dr. Andrew Weil, and holds board certification in Preventive Medicine along with certifications in medical acupuncture and integrative and holistic medicine. He specializes in low dose naltrexone (LDN), autoimmune conditions, chronic pain, integrative oncology, fibromyalgia, chronic fatigue syndrome, mast cell activation syndrome (MCAS), and mold toxicity. Dr. Kim is the author of three books and more than 20 professional articles.

Professional: www.yoonhangkim.com

Clinical: www.directintegrativecare.com