Redefining Primary Care
By Dominique Perkins, Associate Editor, Arizona Physician
Photography by Noble Pictures, jeffnoblepictures.com
From Print Issue - Spring 2025
Dr. Nacchal Nachiappan on Membership Medicine and Physician Autonomy
In an era when the pressures of corporate healthcare often compromise the patient-doctor relationship, Dr. Nacchal Nachiappan, MD, an internal medicine physician and owner of Build Health MD in Arizona, is charting a different course. Through her transition to a membership-based practice, Dr. Nachiappan has found the freedom and autonomy to focus on patient care through long-term relationships and proactive health management.
A PHYSICIAN’S CALLING
When Dr. Nachiappan was a child, there were no cell phones or pagers. However, she recalls that everyone in her small village always knew exactly where to find her father, who was a physician completing his rural year of residency. No matter the time or circumstance, she knew he would always respond to people’s requests.
It was his calling—his identity. Dr. Nachiappan was inspired by his dedication and followed his example as she paved her own path to patient-driven care. Dr. Nachiappan studied at Cornell University and SUNY Upstate Medical University, where she was fascinated by the intricate domino effect of the body’s organs. She was initially drawn to pulmonary and critical care.
However, while in her residency, she became ill during the 1st trimester of pregnancy, and her daughter was born with pink tetralogy of Fallot, a congenital heart condition.
“I’m eternally grateful that my daughter is now healthy, and that we both survived,” she said.
Juggling the personal toll and continued treatment needs for her and her daughter, she decided against pursuing a further specialty and embraced the role of internist, which allowed her to care for all the organs at their various stages and the body as a whole. From here she worked in a variety of roles, from part-time hospitalist to full-time academic physician at the VA. As her career progressed, she realized her limited voice and little control over her schedules and patients were leaving her feeling frustrated and disconnected from her goals as a physician.
“While I love the medicine and pathophysiology of the disease process in the hospital setting—because you can see everything work faster—I realized that the only longitudinal whole person care gave me that true lasting joy of being able to change the course of someone’s life for the better.” she said.
She started asking herself, if I had my own voice and ability to make a change, what would I do? And after careful planning and preparation, she opened Build Health MD, a membership medicine practice, in 2024.
“My frustration resolved the moment I decided to start my own practice,” she said.
“In one sweep, the membership medicine model removes the bureaucracy and the barriers to effective, efficient care.”
She sees most of her patients monthly and enjoys the flexibility this gives her to personalize the care each patient receives. Even going so far as to include yoga and fitness training for patients trying to increase their strength and mobility.
NAVIGATING THE DIRECT-PAY MODEL
Direct pay healthcare models are not new, but in the last few decades they have become a steadily growing trend in the healthcare landscape as both patients and physicians search for a path through the murk of insurance regulations, delayed payments, baffling healthcare policy, misinformation, bureaucratic red tape and exhaustion.
Patients pay a fixed monthly or annual membership fee to be a part of the practice, and in return enjoy increased access to their primary physician through phone and email, and longer office visits with minimal wait times.
“This allows patients to know the fixed cost for the whole year, and they can seek care without worrying about copays or other hesitation,” Dr. Nachiappan said.
“They have peace of mind, to know that their primary care physicians is just a call away, and they don’t have to worry.”
A variety of terms have emerged to describe this new direction in healthcare models, such as concierge medicine, membership medicine, retainer medicine, boutique medicine, and direct-pay primary care. At their core, each of these healthcare models share common goals of patient-centered care that bypass traditional insurance-based models. The terminology, financial structure, cost delivery, and service models, however, differ from practice to practice.
Some direct-pay primary care models only bill insurance for lab and imaging work, with the patient fee covering all in-office visits and calls for the year.
Other concierge practices may charge insurance for visits and procedures, with the patient retainer covering additional or specialized offerings in care or access.
Neither model is a direct replacement for insurance coverage, though. Emergencies and injuries are still a part of life, and a primary care office cannot offer advanced procedures, tests, or hospitalizations. However, for anyone looking to invest in their long-term health, it is an attractive option.
As she has built her patient base, she has noticed it is largely middle-aged patients who seek out membership- based care as they are starting to see the budding issues of aging and want to take charge of their lives and their health. Unless insurance systems change dramatically to value preventative and primary care, membership medicine will likely become the principal primary care model for the future.
Much of today’s traditional insurance-based healthcare is designed for “sick care”, and, whether due to rising prices or narrowing coverage, many patients avoid or delay physician visits—even for issues of growing concern. This exacerbates the severity, urgency, and expense of health issues down the line. Dr. Nachiappan found that implementing a membership medicine model shifted her practice from reactive to proactive and allows her to prioritize relationship-driven care.
A quick triage call for a patient traveling with family might only take a few minutes, but those few minutes could prevent an ER visit to an out of network hospital. As Dr. Nachiappan described it, saving one ER visit would pay for that patient’s entire year of care.
“I find that this is more important than ever in this day of fragmented healthcare,” she said. “For primary care physicians to have the ability and time to care for patients across all the systems, without worrying about payment models, and being able to deliver the care in a way that’s appropriate to the issue at stake—whether it’s by phone, video, clinic, home, or a café.”
THE REWARDS OF RECLAIMING PRIMARY CARE
For others considering transitioning to a membership-based practice model, Dr. Nachiappan shared a little of her own experience in navigating business challenges.
“It’s not as flashy as, ‘Drop 10 pounds and glow by lunchtime,’” she laughed. “But real health isn’t a quick fix—it’s a journey. And while slow, life-changing medicine isn’t always the easiest sell, it’s the only kind that truly lasts.”
Though it will take longer to find the patients who truly value what you offer, she promises it is worth it.
“Then you do form long-term relationships,” she said. “And you can sleep better knowing that you actually helped and touched people’s lives.” Another business strategy Dr. Nachiappan has employed in her practice is to require a minimum contract length, at least initially.
This ensures she will have the time to fully address and resolve her patient’s issues and enjoy the longitudinal care that she has found to be so rewarding. She shared an experience early in her practice’s formation when she made an exception: a patient came in requesting a solo consultation. It seemed both straightforward and urgent, not to mention she was just starting out and could use the business, so she capitulated.
After performing the exam and giving her recommendations, the patient left. But days later she found herself still thinking about that patient, plagued with questions: Did it get better? Worse? Did they know what next steps they need to take? Had they turned up in an emergency room somewhere since leaving her “one time visit”?
“It made me worried,” she said. So much so that she finally made a follow-up call providing additional consultation, and then another, and another.
“I realized: this does not work,” she said of “one-time” care. “I’m better off being a primary care physician.”
This realization solidified her identity and strengthened her practice.
“I love my job as a primary care physician at Build Health, MD,” she said. “And because the focus is on building health for life, I get to live my calling every day. Helping patients create healthier, fuller lives is the most rewarding part of all”. â–
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ABOUT THE AUTHOR
Dominique Perkins serves as Associate Editor for Arizona Physician.