All cash practices

[nope80]

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Lets discuss🙂

Do people have any experience with all cash/partial cash offices in internal medicine and how they have done? I have been doing some reading and found that there are many formats but this still seems to be a rather rare form of practice.

It seems like this in theory should be a great venture if organized properly. It doesn't make sense that people should be able to walk into a doctors office with a 10-20 dollar copay and yet when you go to the vet...the dentist...etc you end up easily paying hundreds of dollars out of pocket each time....

 

[intcards]

Dude, if someone has health insurance why would they choose to go to your fee for service practice instead of one that actually accepts their insurance? If they do not have health insurance then they can't afford your practice. The only clientele for which this model can be successful is for the super rich. And you need to have something really special about your practice to make them want to spend the money. The most common reasons are: 1) you become a world renowned expert, so famous that people will pay out of pocket to see you. 2) you have a concierge practice that offers a gym, medi-spa, 24/7 access by cell phone, appointments at off hrs and weekends, convenient location, etc. These are not uncommon in major metro areas.

 

[Socrates25]

Its not true that all your patients have to be super rich in order to make cash-only work. What is true however is that you'd better have a freaking stellar reputation and OUTSTANDING customer service skills to pull this off.

I've never seen a fresh out of residency grad be able to pull this off -- its always attendings who are very well established in the community for at least 5-10 years who have absolutely amazing bedside manner and super communication/personal attention skills who are able to make it work.

 

[Blackcomb]

I've heard of some partial cash practices that charge a monthly retainer fee, something like $25-$35 per month. That retainer fee allows a PMD to reduce his/her practice population from something along the lines of 5000 --> 500 patients. These "boutique" doctors still take insurance but are no longer constrained to see 25 patients a day and offer longer office visits and some degree of off-hour visits. They also don't require an extensive staff due to reduced patient volume. While they will see patients at slightly off hours, they don't necessarily offer 24/7 call-me-anytime-and-i-will-come-to-your-house coverage.

I actually think this is an attractive model if I were going into primary care. As a patient- would I be willing to pay an additional $30 a month for hour-long visits and more personalized care? Sure- as long as I was middle to upper-middle-class and had some disposable income.

I don't agree with the doctors who scoff at all non-traditional PC office models because they "only cater to the rich". The current Medicare/insurance climate has made it very difficult to run a practice that is both economically viable and allows for good patient care.

 

[CanIMakeIt]

I've heard of some partial cash practices that charge a monthly retainer fee, something like $25-$35 per month. That retainer fee allows a PMD to reduce his/her practice population from something along the lines of 5000 --> 500 patients. These "boutique" doctors still take insurance but are no longer constrained to see 25 patients a day and offer longer office visits and some degree of off-hour visits. They also don't require an extensive staff due to reduced patient volume. While they will see patients at slightly off hours, they don't necessarily offer 24/7 call-me-anytime-and-i-will-come-to-your-house coverage.

I actually think this is an attractive model if I were going into primary care. As a patient- would I be willing to pay an additional $30 a month for hour-long visits and more personalized care? Sure- as long as I was middle to upper-middle-class and had some disposable income.

I don't agree with the doctors who scoff at all non-traditional PC office models because they "only cater to the rich". The current Medicare/insurance climate has made it very difficult to run a practice that is both economically viable and allows for good patient care.

That is really not a bad idea for private practice that is not dependent on medicare/medicaid for their main business. 👍

 

[survivordo]

Its not true that all your patients have to be super rich in order to make cash-only work. What is true however is that you'd better have a freaking stellar reputation and OUTSTANDING customer service skills to pull this off.

I've never seen a fresh out of residency grad be able to pull this off -- its always attendings who are very well established in the community for at least 5-10 years who have absolutely amazing bedside manner and super communication/personal attention skills who are able to make it work.

A mentor of mine who is a family practice physician (mostly sees adults) is currently making the transition to this type of practice. Basically he's sick of all the medicare/insurance BS and it will be something along the lines of 25 for an established patient visit, 50 for new patient/yearly physical. But as Socrates pointed out, he is VERY well established and his patient's absolutely adore him, most are lower-middle to upper-middle class. I will be interested to see how it works out!

-Survivor D.O.

 

[StevenRF]

Been reading up on this lately too. From the operations side, the key seems to be reducing overhead, with the simplest being you performing everything and no staff in a small office. The more people or things you have to have to due your job, the more patients it takes per day to just break even. I read somewhere that one guy doing a complete solo practice broke even after his 4th patient of the day.

For the insured patient, the cost of them paying out of pocked the $50-75 to whatever price per visit vs their copay has to get patients something, and that value proposition is usually immediate access that day or the next with their primary provider, extended visits, and whatever else you want to throw in. Essentially they are paying for what insurance won't, facetime.

I think the key is doing what most primary care physicians wont do, and that is market segment. Some do, and focus on things like geri, HIV, chronic pain, metabolic syndrome, etc. From some of the examples I've seen, if you build your practice to market to patients who put a premium on their patient physician relationship, you can justify these out of pocket costs to the patient.

 

[take the shot]

This is concierge medicine and is one of the ways physicians avoid dealing with insurance companies. I know a group of outstanding pulmonologists that charge each pt $5000. They do not bill insurance companies or deal with Medicare/Medicaid; the pt uses their insurance coverage for labs and diagnostics.. For this fee the pt has their cell phone numbers and are available to all pts 24/7. They still have regular office visits. Pts need some type of insurance for hospitalization and the hospital does that billing. These docs will also care for the pt in the hospital.

I have heard my attendings talk about their frustration with billing and insurance companies and how it limits their ability to take good care of pts. I really wish this country limited the power of insurance companies. It has made it really hard to do what's right for pts. I can understand why some physicians have opted to develop practices where they can care for the patients without the hassle of insurance.

 

[notinkansas]

Dude, if someone has health insurance why would they choose to go to your fee for service practice instead of one that actually accepts their insurance? If they do not have health insurance then they can't afford your practice. The only clientele for which this model can be successful is for the super rich. And you need to have something really special about your practice to make them want to spend the money. The most common reasons are: 1) you become a world renowned expert, so famous that people will pay out of pocket to see you. 2) you have a concierge practice that offers a gym, medi-spa, 24/7 access by cell phone, appointments at off hrs and weekends, convenient location, etc. These are not uncommon in major metro areas.

There are MANY reasons why people with insurance would choose to go to a cash only practice. The biggest of these is to avoid the intrusion of government into one's life. A growing number of people are getting uncomfortable with all the screening and documenting and reporting to government agencies that is required in order to comply with Medicare regulations, for one.

It is a TOTALLY FALSE statement that "the only clientele for which this model can be successful is for the super rich" While it is true that there are some practices that cater to this clientele, many do not.

For many people, simply not reporting their information to an insurance company would be enough of a reason to go to a cash practice. There are even a few outpatient surgery centers that are cash only. Example: http://www.surgerycenterok.com

Here is an organization that is very helpful to many doctors running insurance free practices: http://www.aapsonline.org

There are many, many more options than we are lead to believe in training for practice of medicine.

 

[Pseudopseudonym]

Dude, if someone has health insurance why would they choose to go to your fee for service practice instead of one that actually accepts their insurance? If they do not have health insurance then they can't afford your practice. The only clientele for which this model can be successful is for the super rich. And you need to have something really special about your practice to make them want to spend the money. The most common reasons are: 1) you become a world renowned expert, so famous that people will pay out of pocket to see you. 2) you have a concierge practice that offers a gym, medi-spa, 24/7 access by cell phone, appointments at off hrs and weekends, convenient location, etc. These are not uncommon in major metro areas.

What an ignorant statement. Sounds like you've been brainwashed by academic medicine.