According to research conducted by The Commonwealth Fund, the United States has the most expensive health care system in the world. And yet, out of the 11 countries studied, we come in dead last for quality of care, access to care, and health outcomes. One-third of American adults say they didn’t take a prescription drug, visit a doctor when sick, or receive recommended care because it was too expensive.
Access to quality and affordable health care is an issue that affects everyone. But even with the Affordable Care Act (ACA), families struggle to pay for their insurance and find doctors who have time to listen to their concerns.
Some doctors are taking matters into their own hands and stepping out of the modern health care system entirely, ditching insurance for a cash-only system. The concept might seem radical at first, but this is how physicians have treated patients throughout history, at least until the 1950s when commercial insurance turned patient care into a profitable business.
Cash-only doctors have complete freedom in how much time they spend with each patient and what they charge for that time. You could call it “slow medicine.” And this new pay-as-you-go model is resonating deeply with doctors and patients alike.
But is a cash-only doctor right for you? Let’s take a look.
The Problem With Modern Health Care
If you’ve been to see a typical doctor lately, you likely left feeling as if you barely spoke to them. Today, a visit to the doctor usually means long waits and short visits, often too short to really talk to your doctor about your health concerns. How did we get to this point?
The current system is not the fault of physicians. Many of them hate that they get to spend so little time with their patients; after all, they went into medicine to help people and make a difference. As USA Today reports, these short visits are due to declining reimbursements from insurance companies. Doctors must see more patients or perform more procedures for their clinics or hospitals to stay afloat financially. Some doctors working in a hospital setting say they’ve been asked to see one patient every 11 minutes, and The Atlantic reports that most doctors only spend 12% to 17% of their day with patients. The rest of their time is spent on paperwork, going over lab work, and interacting with staff.
In other words, insurance companies run the show now, not doctors, and certainly not patients.
These short visits have a negative impact on the doctor-patient relationship. It’s hard to talk to your doctor about your concerns or build trust in them when they’re in and out of the room within minutes. Shorter visits also mean that a patient is likely to leave with a prescription instead of knowledge about behavioral changes that might make more of an impact, simply because the doctor doesn’t have time to have those conversations.
The problem is expected to get worse with the 2019 proposed Physician Fee Schedule. Medical industry journal Patient EngagementHIT writes that the new fee schedule would further limit reimbursements for evaluation and management services. That means doctors would get paid the same amount for each evaluation, whether the patient has a stubbed toe or a complex health condition that could require extensive questioning to diagnose. The reduced reimbursements could put further pressure on physicians to shorten appointments.
Record Keeping Requirements
Even if you’re able to get a full 15 minutes with your doctor, your doctor might spend most of the time staring at their tablet and typing in your responses, rather than truly listening to what you’re saying. This is, again, the fault of insurance companies, as well as the government.
Doctors spend an enormous amount of time keeping up with electronic health records (EHR) to meet “meaningful use requirements.” If they don’t demonstrate that they’re using EHR to improve patient care and communicate with insurers, they won’t be able to receive reimbursement for appointments or incentives from the government.
If they don’t meet meaningful use requirements, they’re penalized financially. Dr. Linda Girgis, writing for Physician’s Weekly, states, “Patients take this lack of eye-to-eye contact as a sign that we are more interested in their digital record than them. They feel we are no longer listening to them. They don’t realize that we don’t want to be doing this.”
Doctors want to put the tablet down and truly listen to what you have to say. But in the current system, they simply can’t. One of the benefits of the 2019 proposed Physician Fee Schedule is that it would reduce the number of notes and forms doctors are required to submit to qualify for reimbursement.
Doctors are so pressed for time that they often feel pressured to jump to your “chief complaint.” A 1999 study published in the Journal of the American Medical Association (JAMA) found that most physicians redirected a patient’s opening statements after just 23 seconds, and only one out of four patients were allowed to finish what they had to say. This redirection can lead to missed opportunities to gather potentially important information and can lead to an overall lower quality of care and diagnosis.
The Affordable Care Act
The Affordable Care Act (ACA) further compounds the problem. The ACA has helped many people obtain health insurance who wouldn’t ordinarily receive it. However, because insurance companies have been forced to take on many more “high-need” — in other words, expensive — patients, they’ve passed on those extra expenses to consumers in the form of high-deductible health plans and higher copays. So, even if you have insurance and your monthly premiums are higher than they used to be, you might be paying even more to see your family doctor or receive specialized care because of high deductibles.
All of these problems are forcing doctors and patients to realize that the system, as it is now, is fundamentally broken. And since necessity is the mother of invention, a better solution is slowly emerging around the country.
The Rise of Cash-Only Doctors
Cash-only doctors, also called direct-pay doctors or direct primary care doctors, are medical professionals who have decided to accept only cash for their services. They don’t accept any insurance, including Medicare or Medicaid. Typically, they charge patients a monthly membership fee, which can range from $50 for an individual to $150 or more for an entire family. This membership fee covers all appointments, physicals, EKGs, most tests, and even stitches.
It’s important to realize that “cash-only” is a blanket term for this type of service. These physicians do accept check and credit card in addition to cash; they just don’t accept any form of insurance.
Direct primary care is sometimes labeled as “concierge care”; however, the two types of practice are slightly different. Concierge practices charge patients a monthly fee for direct access to doctors and often same-day appointments. However, concierge care is more expensive than direct primary care. According to Patient EngagementHIT, concierge practices typically charge patients $182 per month for immediate access to their doctor. The biggest difference between direct primary care and concierge care is that the latter still bills insurance companies for services.
Benefits of Cash-Only Doctors
There are many benefits of using a cash-only doctor or clinic.
1. More One-on-One Time
One of the biggest benefits of cash-only doctors is that you typically get more one-on-one time with your physician. When you pay your doctor directly, they work for you, not the insurance companies. If you need an hour of their time, you get an hour.
Ashley Maltz, a cash-only doctor, writes on MedPage that when she worked in a traditional clinic, she spent an average of 16 hours per week just writing notes to satisfy insurance companies so she could get reimbursed for her services. Now, she no longer has to do that and can instead spend more time with her patients.
2. More Flexibility With Appointments
According to the Journal of the American Board of Family Medicine, in an average family practice, each full-time physician is typically assigned 2,500 patients and some are assigned up to 4,000. It’s no wonder we feel like cattle being herded through the branding gates when we arrive for an appointment.
Cash-only doctors have far fewer patients. Some may have as few as 200, while others may have as many as 1,000. Limiting their number of patients means these doctors can spend more time talking and listening to each one. They can also offer their patients same-day or next-day appointments.
Cash-only doctors also have complete freedom in how they see their patients. In-office visits are often necessary, but many medical issues can be diagnosed using technology such as FaceTime or Skype. Doctors also communicate with patients through text or email to further save time and make themselves more available.
3. Price Transparency
A cash-only system allows you to see exactly how much you’re paying for each service, even for complicated procedures.
For example, the Ocean Surgery Center in Torrance, California, a cash-only outpatient surgery clinic, posts the costs for all surgeries online. According to its estimates, procedures at the Center cost 40% to 60% less than the same procedures elsewhere. Why? Because it has a staff of around 40 people, and no one has to waste time haggling with insurance companies or doing medical coding to ensure they get reimbursed. With insurance out of the picture, they’re far more efficient.
According to TIME magazine, most insurance companies specifically bar hospitals from publicly disclosing their reimbursement rates. That’s why if you call around checking prices for a specific service, such as a knee replacement, you might find one hospital charging $16,000 for the procedure, while a hospital in the next town charges $65,000.
Also, by cutting out the middleman, cash-only physicians can offer many medications to their patients at a low cost, often wholesale plus 10%.
4. Better Care
According to researcher Dave Chase, interviewed by AARP, doctors don’t always have the freedom to treat their patients as they see fit. In order to get reimbursed by insurance companies, physicians often have to treat a patient’s chief concern based on how the insurance company says they should treat that concern. So, they order a test or send the patient to a specialist instead of talking to them about what’s happening or using alternative treatments.
Cash-only doctors have the freedom to treat their patient’s health concerns as they see fit. After all, this is why they got into medicine. When they have the time and freedom to do so, most doctors can develop a comprehensive treatment plan that includes behavioral changes, procedures, and medications that can address multiple issues.
Drawbacks of Cash-Only Doctors
As you might imagine, there are some drawbacks to using a cash-only system for your medical care.
1. Increased Costs
If you’re already paying $800 per month for health care, paying an additional $150 per month to become a patient of a cash-only doctor may be hard to swallow. However, plenty of families are willing to invest this extra money to receive better care from their family physician. Their commercial insurance is then a safety net in the event of a serious health problem or unexpected accident.
If you’re on Medicaid, it can be challenging to afford the extra expense of a cash-only doctor. Some cash-only doctors provide discounted or even free care to Medicaid recipients on a case-by-case basis. Currently, only one bill, H.R. 3315, has attempted to bridge the gap between Medicaid recipients and cash-only doctors by reimbursing monthly membership fees. However, the bill died in Congress and, thus far, no other bill has taken its place.
Critics of a cash-only system say that it creates a barrier to care for low-income patients, and this is certainly a compelling argument. However, if legislators could work together on a reimbursement plan for Medicaid recipients, these barriers wouldn’t exist, and everyone could have access to lower-cost, higher-quality care.
2. Might Not Be Suitable for Severe Health Conditions
It’s important to keep in mind that family or general practitioners are usually the ones who adopt a cash-only business model, although some dentists and internists are hopping on board. While these physicians typically meet 85% of patient needs, they’re not equipped to handle severe health complications or conditions that require the expertise of a specialist.
This means that if you have severe health problems, you’ll still need to rely on commercial health insurance and the attending specialists and high-tech care of a traditional hospital.
What a Cash-Only Health Care System Looks Like
Brent Long and his family belong to Black Bag Family Healthcare in Johnson City, Tennessee. As Business Insider reports, Long and his family pay a $150 per month membership fee, which gives them unlimited access to their doctor, appointments that last as long as necessary, and even house calls if they’re too sick to come to the office. Members of this program also receive additional free services, such as yearly physicals, acupuncture treatments, and breathing treatments. Medications are at a wholesale cost.
My aunt lives in rural Tennessee. She and my uncle pay their doctor a flat monthly fee of $75, and this monthly payment gives them the ability to call or email her with any health question at any time. They usually get same-day appointments, and when my aunt came down with a virulent strain of influenza last winter, her doctor made several house calls to see her.
With a cash-only doctor, health care becomes personal again. You have the opportunity to get to know and trust your physician and, more importantly, they have the opportunity to get to know you. This familiarity and trust naturally lead to better care.
How to Find a Cash-Only Doctor
The Henry J. Kaiser Family Foundation reports that there are over 968,000 practicing physicians in the United States. It’s difficult to determine just how many of these use a cash-only system; AARP estimates there are 5,000 direct-care physicians nationwide, while CBS estimates that 4% to 6% of physicians have transitioned to a cash-only model.
Whatever the figure, the good news is that the number of cash-only doctors keeps increasing. Researcher Dave Chase, interviewed by AARP, estimates that in the years to come, 16% of physicians or more will use a cash-only business model.
So, how can you find a cash-only doctor in your area?
1. The Wedge of Health Freedom
One of the best tools for finding a cash-only doctor, practice, or clinic is The Wedge of Health Freedom. This website was founded by Twila Brase, RN, PHN, to give patients the ability to connect with doctors who have left the insurance system. Currently, the website lists around 300 cash-only doctors and clinics.
2. DPC Mapper
The DPC Mapper, operated by DPC (Direct Primary Care) Frontier, is another valuable resource. DPC Frontier was founded in 2015 by Dr. Philip Eskew, a family practice physician who also volunteers as the general counsel of the Direct Primary Care Coalition. Currently, the DPC Mapper has almost 900 listings for cash-only physicians around the country.
3. Word of Mouth
Most cash-only physicians don’t spend time marketing their businesses or trying to get media attention, so unless they’re listed on The Wedge or DPC Mapper — and many still aren’t — they can be difficult to find. Instead, they rely on word-of-mouth recommendations from their current patients.
This means you might find a local cash-only doctor if you ask around. Even your current general practitioner might know of a colleague who’s opened up a cash-only practice. You won’t know unless you ask.
4. Doctor On Demand
If you can’t find a local cash-only doctor in your area, another option is to use an online doctor through a service such as Doctor On Demand. Using your phone, tablet, or computer, you can connect with a doctor 24/7 with no appointment necessary.
The benefit of using a service like Doctor On Demand is that the cost is significantly less than going to an urgent care center or paying cash for an appointment at a typical physician’s office. An office visit costs a flat rate of $75, while therapy sessions cost $79 to $229. Doctor On Demand does take insurance, so they’re not strictly “cash only.”
Of course, Doctor on Demand can’t serve patients with serious or complicated medical conditions, and they can’t handle emergencies such as a broken arm or a cut that needs stitches. However, they can treat 18 out of the top 20 conditions that people visit urgent care for, including:
- Back pain
- Bronchitis and pneumonia
- Cellulitis and skin infections
- Colds, coughs, and congestion
- Headaches and migraines
- Rashes and skin conditions
- Sinus infections
- Sports injuries
- Sprains and bruises
- Urinary tract infections
- Vomiting and diarrhea
- Mental health conditions such as depression, post-partum depression, and anxiety
Doctor on Demand is also available for medical advice when you’re not sure what to do or where to go.
While Doctor On Demand isn’t strictly a cash-only health care option, it does provide medical assistance at a significantly lower price than urgent care, which often charges patients several hundred dollars just for walking in the door.
More and more people are seeing the benefits of slowing down in all aspects of life. With the increasing popularity of movements like slow living, slow food, slow parenting, and slow fashion, it seems likely that slow medicine will eventually catch on too. Slow medicine has the potential to make an enormous difference in the quality of medical care we receive in this country, and that’s an issue that affects us all, regardless of age or income level.
Would you consider using a cash-only doctor? Why or why not?