A Solo Internist Is Opening a Cash-Pay Practice in Kingsport. Tennessee Has Already Set an Expiration Date on Its Quality Scoring of the Local Hospital Monopoly.

A board-certified internist is opening a cash-pay primary care practice in Kingsport, Tennessee. Memberships start at $75 a month. The hospital in the same city belongs to the largest state-sanctioned hospital monopoly in the United States, and Tennessee has now written an expiration date into its quality and access scoring of that monopoly.

Birch Health is at 247 Broad Street, founded by Dr. Benjamin Emery, an internal medicine physician who grew up in the area. The practice’s own site lists a July 1, 2026 founding date and still describes the clinic as opening, so the date it starts seeing patients is not something a primary source pins down. What the site does pin down is the terms.

What the practice actually charges

Birch publishes its terms in plain sight, which is more than most new practices manage. The adult membership runs $75 a month plus a $150 annual membership fee per patient. On the access side that covers in-office visits and telemedicine, unlimited messaging, prioritized scheduling, care navigation and specialist referrals. The services list adds annual physicals, preventive care and screenings, chronic disease management, and labs and medications at cost. Family plans and single-visit pricing for people who aren’t members sit on the same page. The clinic runs 8 to 5 Monday through Friday, with Saturdays by appointment.

Blend the monthly fee and the annual fee together and you get roughly $87.50 a month. That’s our arithmetic on Birch’s two published numbers, not a figure the practice quotes. It lands inside the AAFP’s published range of $50 to $100 a month for DPC memberships. Whether a DPC arrangement blocks someone from contributing to a health savings account turns on a different test, which the IRS laid out in Notice 2026-5. An arrangement stops qualifying once the aggregate fees for an individual pass $150 in a month, and fees billed for longer stretches, up to a year, get measured against that limit annualized, which the notice puts at $1,800 for a single individual in 2026. The same notice says the sole compensation for the care has to be a fixed periodic fee. How a monthly membership with a separate annual fee alongside it reads against both tests is a question for a tax adviser, and not one the notice settles on its face. Any practice thinking about charging members per visit on top of a membership should read that sole-compensation clause twice. Costs and structures vary by practice.

Emery trained at the University of Tennessee College of Medicine, took an MPH at Boston University, and finished residency at UT’s Chattanooga campus. Birch’s own listings name one physician, him. Hold that number.

The market he opened into

Kingsport is Ballad Health country. Holston Valley Medical Center sits in the city, one of 20 hospitals in a system covering a 29-county swath of Appalachia and about 1.1 million people. Ballad exists because lawmakers in Tennessee and Virginia waived federal antitrust law in 2018 so two competing chains could merge, over the Federal Trade Commission’s objection.

What the region got instead of competition was a Certificate of Public Advantage: a 10-year deal under which the state, rather than antitrust enforcement, holds the system accountable. KFF Health News found that Ballad missed roughly three-quarters of Tennessee’s quality-of-care goals across four fiscal years. Tennessee’s answer was to move the bar. The score required to show a “clear and convincing” public benefit dropped from 85 out of 100 to 70, with dissolution off the table down to 55. As part of the same announcement, Tennessee said it wouldn’t score Ballad at all the following year, to give the company time to adjust to the new process, and reset baseline measurements stay unpublished until 2027.

June 30, 2028

Then the legislature set a clock. The Senate passed the bill on March 26, the House on April 6, and the Senate agreed to the House’s amendment on April 16. The governor signed it on May 5, 2026, and the secretary of state numbered it Public Chapter 904 on May 18. It provides that any certificate of public advantage in effect on June 30, 2028 automatically expires. Pricing restrictions outlive it, but only until the fifth anniversary of that expiration or until a new inpatient acute care hospital opens in the geographic service area, whichever comes first. The attorney general supervises whatever restrictions remain, and they can be changed only by mutual written agreement.

The FTC told Tennessee not to do this. Allowing a COPA to expire without a competitor in the market, the agency warned, “enables a monopolist to exercise substantial market power unconstrained by state regulatory oversight or antitrust enforcement against merger-related harms.” The agency called it “the worst possible outcome for patients.”

So the sequence for this corner of Appalachia reads: antitrust waived in 2018, state scoring softened in 2025, state scoring gone in 2028. A doctor opening an independent practice there in 2026 is doing it against that backdrop, whether or not that’s why he did it.

The Counterargument

The strongest case against reading any of this into Birch Health is a numbers case, and it’s a good one. The AAFP puts the average DPC panel at about 413 patients. Ballad is the only hospital option for most of the 1.1 million people in its service area. Hospital market power lives in inpatient rates, facility fees and specialty contracts, and a membership primary care practice touches none of them. Letting the COPA lapse does not by itself put a second hospital in the market either. Tennessee did separately end its certificate-of-need requirement for acute care hospitals, in a bill the governor signed the same day as the COPA measure and the secretary of state numbered Public Chapter 887. That exemption doesn’t take effect until July 1, 2030. The FTC called the potential opening of a new inpatient hospital a step toward rebuilding the competition the merger removed, and objected to the timing in the same letter: a 2030 date leaves two years in which Ballad faces neither state oversight nor a competitor. Every remedy in that paragraph is a hospital, and a cash-pay clinic on Broad Street isn’t one.

All of that holds, and it still leaves something out. Primary care is where the referral gets written, and after June 2028 nobody in Tennessee state government will be scoring Ballad on whether patients can get an appointment. Virginia keeps reviewing the system every year under its own separate agreement, on its own timeline. A patient in that 29-county region who wants a doctor with no institutional stake in where they go next will have one reliable way to get one, which is to pay for it directly.

Birch Health doesn’t fix a monopoly. It gives a few hundred people a door that isn’t the only door. In a region that has had one door since 2018, that’s a smaller thing than the FTC is asking for and a larger thing than nothing.