Cash Pain Practice?

[Status Sciaticus]

Advertisement - Members don't see this ad

How realistic is it to have a primarily cash based pain practice or a large percentage of collections be cash based?
This is primarily in response to the continuing CMS cuts that will continue to happen, especially for fee-for-procedure/service spectrum of billing.

 

[lobelsteve]

You will be looked down upon by every other doctor. And the medical board. And the DEA.
Good luck with that.

 

[Status Sciaticus]

You will be looked down upon by every other doctor. And the medical board. And the DEA.
Good luck with that.

Thanks for replying. For what reason particularly? Assuming this is not a pill mill scheme.
Wouldnt doing interventional procedures without dealing with denials and insurance headaches, shortchanging you be preferable to the alternative?

 

[jsaul]

about 15 percent of my procedures are pure self pay. There is no way you would be able to survive on 100 percent cash pay for pain procedures.
most of your procedures are on people above 65, people with personality disorders, needy people, poor people all of whom typically dont pay cash.

 

[Status Sciaticus]

about 15 percent of my procedures are pure self pay. There is no way you would be able to survive on 100 percent cash pay for pain procedures.
most of your procedures are on people above 65, people with personality disorders, needy people, poor people all of whom typically dont pay cash.

Do you then typically weed out medicare/medicaid patients or keep them to a minimum?

 

[jsaul]

i dont weed out medicare patients. I welcome them.

 

[DubVille]

Seems to be a small market. What would you offer that 10 other practices dont in the area?

I send out for PRP/stem cell cash based to another doc. Idk how well he is doing but as much as I sometimes struggle with our patient population, I'd take my position over his.

I think it would be hard to not do too many procedures or get into meds if the shots dont work.

 

[Ligament]

Do not prescribe controlled substances except for acute post op pain on rare occasion, and there is no issue with anything. Problem is finding a 100% cash pay population.

 

[DrSpine]

There's absolutely nothing wrong with a cash only based practice. I would not write opioids though at all; that's pretty much asking to be in cuffs within a few days. The problem is, it's almost impossible to get a fully cash based practice going.

 

[myrandom2003]

Try being out of network first and see how that goes.

It might be easier sell than pure cash.

 

[hyperalgesia]

How realistic is it to have a primarily cash based pain practice or a large percentage of collections be cash based?
This is primarily in response to the continuing CMS cuts that will continue to happen, especially for fee-for-procedure/service spectrum of billing.

The problem is your practice will live or die based on referrals and new patients. Unless you have a captive referral base, it will consume you.

And the way our system works, health insurance and government payers have enormous influence over this. Patients have basically already paid for their care in the form of insurance premiums and now it's just a question of who accepts their insurance.

Once you accept an insurance, you are bound by contract to these patients and not allowed to charge cash for covered procedures.

The system is rigged against cash.

The only way to do cash only is go to an area where you have a monopoly on your specialty or do things that are not covered by insurance.

 

[Pain Applicant1]

I don't ever accept cash. If the pts pay you in cash they accept something in return, usually opioids. Procedures are too expensive for most patients.

With that said, my sister used to work for a cash pain practice in NYC. Perhaps some on this board know this practice. This guy did well but most of the pts were famous stars, politicians, etc. What a racket.

 

[avalon10]

about 15 percent of my procedures are pure self pay. There is no way you would be able to survive on 100 percent cash pay for pain procedures.
most of your procedures are on people above 65, people with personality disorders, needy people, poor people all of whom typically dont pay cash.

This is not necessarily true. It depends where you are. There are locations where tons of doctors are cash-only, generally catering to those who can afford it. It can be very competitive.
Just because you don't think it would work where you live doesn't mean that you can extrapolate to the entire country.

 

[avalon10]

I don't ever accept cash. If the pts pay you in cash they accept something in return, usually opioids. Procedures are too expensive for most patients.

With that said, my sister used to work for a cash pain practice in NYC. Perhaps some on this board know this practice. This guy did well but most of the pts were famous stars, politicians, etc. What a racket.

Why is that a racket?? It's probably a great business model . I also know of a practice in NYC that is like this.

 

[NJPAIN]

Only a few ways this can work:
1. You have to be in the perfect demographic, like upper west side NYC where money is no object and you are the only doc anywhere around that does a particular procedure or you are part of an elite surgical group or hospital (such as HSS) and their patients only go where they are sent and they are only sent to you.
2. You are the candy man and candy is cash only.

#1 is exceedingly rare. Most are #2.

 

[avalon10]

Only a few ways this can work:
1. You have to be in the perfect demographic, like upper west side NYC where money is no object and you are the only doc anywhere around that does a particular procedure or you are part of an elite surgical group or hospital (such as HSS) and their patients only go where they are sent and they are only sent to you.
2. You are the candy man and candy is cash only.

#1 is exceedingly rare. Most are #2.

#1 is what I was talking about

 

[SommeRiver]

I have some pts that get shots and pay cash for it, but I do not recommend cash for meds despite my not having a good way to vocalize why I feel that way.

I just wouldn't do it.

 

[Dr. Ice]

Greg Lutz

 

[NJPAIN]

If you have that demographic and an “exclusive” on a procedure that is going to last, go for it. Just realize that someone who is just an RVU machine MAY be able to setup shop nearby, charge $750 for your $7500 procedure and then it’s all over. There aren’t too many companies that will give you a protected territory for a technology except perhaps DiscSeel maybe.

 

[NJPAIN]

Greg Lutz

Bingo or should I say cha-Ching?!

 

[jsaul]

This is not necessarily true. It depends where you are. There are locations where tons of doctors are cash-only, generally catering to those who can afford it. It can be very competitive.
Just because you don't think it would work where you live doesn't mean that you can extrapolate to the entire country.

Ok , I'm saying it can not work for a traditional pain practice

It could work for a sports type practice where the doc is charging top dollar for prp, bmac,

This is not necessarily true. It depends where you are. There are locations where tons of doctors are cash-only, generally catering to those who can afford it. It can be very competitive.
Just because you don't think it would work where you live doesn't mean that you can extrapolate to the entire country.

Ok, cash only is not going to work for a traditional pain practice doing spinal injections rfa scs etc


It could work for a sports practice located in a high earner area big city. Where the doc is charging top dollar for prp, a2m, bmac, etc and only have to see 10 or so patients a day to be successful . Its a hard practice to get going from the ground up

 

[avalon10]

Ok , I'm saying it can not work for a traditional pain practice

It could work for a sports type practice where the doc is charging top dollar for prp, bmac,

Ok, cash only is not going to work for a traditional pain practice doing spinal injections rfa scs etc


It could work for a sports practice located in a high earner area big city. Where the doc is charging top dollar for prp, a2m, bmac, etc and only have to see 10 or so patients a day to be successful . Its a hard practice to get going from the ground up

It's definitely the exception rather than the rule.

 

[Pain Applicant1]

Why is that a racket?? It's probably a great business model . I also know of a practice in NYC that is like this.

I imagine it's likely the same practice if most of the pts are celebrities. Why is it a racket? Well, paying several thousand dollars for something you can pay a couple of hundred dollars for I think qualifies it. I do agree with you though, from a business perspective it is a great model.

I have no problem milking celebrity status people if they're willing to pay for it. I wouldn't like it if it was taking advantage of the system which affects us all or lower SES folks. That would just be being a bully and no one likes bullies.

 

[sloh]

Do any of you know how much physicians who do strictly PRP/stem cells make (after overhead)?

 

[avalon10]

I imagine it's likely the same practice if most of the pts are celebrities. Why is it a racket? Well, paying several thousand dollars for something you can pay a couple of hundred dollars for I think qualifies it. I do agree with you though, from a business perspective it is a great model.

I have no problem milking celebrity status people if they're willing to pay for it. I wouldn't like it if it was taking advantage of the system which affects us all or lower SES folks. That would just be being a bully and no one likes bullies.

To me calling it a "racket" implies that it's illegitimate business in some way. What is a racket about offering people a service that they're willing to pay cash for? How is that "milking" celebrities?!?

I don't know how you could argue that a business like that is taking advantage of lower SES patients or bullying anyone?!?

 

[Pain Applicant1]

To me calling it a "racket" implies that it's illegitimate business in some way. What is a racket about offering people a service that they're willing to pay cash for? How is that "milking" celebrities?!?

I don't know how you could argue that a business like that is taking advantage of lower SES patients or bullying anyone?!?

Charging someone significantly more for the exact same thing or service they can get elsewhere is ripping people off. But if those with the means know what they're being charged and agree to it, by all means, charge them for it. I have no issue with this. People have the right to get ripped off.

For the other 99%, medicine is not a free market. It's not like pts shop at amazon or at different stores to compare prices. There is a significant power differential between a doctor and a pt and pts tend to be in extraordinarily vulnerable states when they are seeing you. This is not a level field and pts, for the most part, will abide by nearly any recommendation you make. This leaves a lot of room to easily take advantage of someone. Even if a pt questions your recommendation, it is very easy to use fear to convince them to accept it.

Couple the above reasons that few pts understand how billing works or how much they will be charged and you a very complex situation. Pts often have no idea what something costs until way after the fact.

 

[avalon10]

Charging someone significantly more for the exact same thing or service they can get elsewhere is ripping people off. But if those with the means know what they're being charged and agree to it, by all means, charge them for it. I have no issue with this. People have the right to get ripped off.

For the other 99%, medicine is not a free market. It's not like pts shop at amazon or at different stores to compare prices. There is a significant power differential between a doctor and a pt and pts tend to be in extraordinarily vulnerable states when they are seeing you. This is not a level field and pts, for the most part, will abide by nearly any recommendation you make. This leaves a lot of room to easily take advantage of someone. Even if a pt questions your recommendation, it is very easy to use fear to convince them to accept it.

Couple the above reasons that few pts understand how billing works or how much they will be charged and you a very complex situation. Pts often have no idea what something costs until way after the fact.

1. No, it is not ripping people off. Do you think that the average wealthy person paying cash for procedures at HSS is some rube who doesn’t know that they could be having the same procedure done somewhere under their health insurance?!?
Selling someone the same product they can get somewhere else at a different price is not ripping them off. The reason that people pay cash for procedures at HSS is that they believe that they’re getting a superior product there.
2. The rest of your comment is pretty irrelevant to the topic at hand.

 

[geauxg8rs]

1. No, it is not ripping people off. Do you think that the average wealthy person paying cash for procedures at HSS is some rube who doesn’t know that they could be having the same procedure done somewhere under their health insurance?!?
Selling someone the same product they can get somewhere else at a different price is not ripping them off. The reason that people pay cash for procedures at HSS is that they believe that they’re getting a superior product there.
2. The rest of your comment is pretty irrelevant to the topic at hand.

I remember in residency a wealthy patient ask our attending about a spinal cord stim. Wanted to pay cash for the implant because he didn’t want to deal with waiting for prior auth. He was the kind of patient who never had to wait in the ER. Goes straight to an empty wing

 

[Status Sciaticus]

There is no concierge model in pain medicine?

 

[Ducttape]

This is not necessarily true. It depends where you are. There are locations where tons of doctors are cash-only, generally catering to those who can afford it. It can be very competitive.
Just because you don't think it would work where you live doesn't mean that you can extrapolate to the entire country.

there are very few areas in the country where there is a significant enough wealthy population to afford a cash only for procedures. you are catering to the 0.5% who can afford the cost. for your average American, a single office based epidural is 1% of their yearly salary...



concierge pain medicine is also not yet a "big thing". I would suspect that there are a few selected doctors, but again the number of people who can afford would be low.

 

[avalon10]

there are very few areas in the country where there is a significant enough wealthy population to afford a cash only for procedures. you are catering to the 0.5% who can afford the cost. for your average American, a single office based epidural is 1% of their yearly salary...



concierge pain medicine is also not yet a "big thing". I would suspect that there are a few selected doctors, but again the number of people who can afford would be low.

No kidding. But my point is that those areas do exist and so do doctors who work in concierge models, likely in every specialty. Including pain/spine/orthopedics.

And if you don't think that they do, you're wrong.

 

[lobelsteve]

No kidding. But my point is that those areas do exist and so do doctors who work in concierge models, likely in every specialty. Including pain/spine/orthopedics.

And law enforcement and medical boards afford those practices extra scrutiny.

 

[avalon10]

And law enforcement and medical boards afford those practices extra scrutiny.

Not true at all. If you had been exposed to practices like this, you'd understand better. I'm guessing you haven't.

 

[lobelsteve]

Not true at all. If you had been exposed to practices like this, you'd understand better. I'm guessing you haven't.

I have. From working with medical boards and the DEA. Have fun with that if you go that route.

 

[avalon10]

I have. From working with medical boards and the DEA. Have fun with that if you go that route.

Clearly you aren't familiar with the kind of practice I am talking about. Just because you have worked with medical boards/DEA for doesn't mean you are. Again, just because you haven't been exposed to it doesn't mean it doesn't exist.

 

[Ronin1]

We have a concierge spine guy in town. All cash for his fee. Another couple of spine guys have a concierge slot as part of their practice. Cash evaluation next day appointment model. I think that I could do this in my area but as I have significant legacy opioid patients I would not like the perception of cash for pills that this may produce.

 

[Centurion38]

Cash and Opioids don't mix. Even if all you are offering is injections and spine/sports you'll be on the radar. No thanks

 

[Pain Applicant1]

1. No, it is not ripping people off. Do you think that the average wealthy person paying cash for procedures at HSS is some rube who doesn’t know that they could be having the same procedure done somewhere under their health insurance?!?
Selling someone the same product they can get somewhere else at a different price is not ripping them off. The reason that people pay cash for procedures at HSS is that they believe that they’re getting a superior product there.
2. The rest of your comment is pretty irrelevant to the topic at hand.

I guess you bring up a valid point. I still see it as a rip off and a waste of money bit if wealthier folks wish to pay more they should have at it. My business models are the complete opposite as I like to operate like Walmart.

Why would someone pay more? Better quality? I guess it's a possibility. I'd like to think I'm the best at LESI but after a few thousand, do providers really differ? I think an interesting psychology develops in certain people when prices go up. Some people assume if they pay more they're getting a better product, such as what happened with Peleton.

 

[Pain Applicant1]

Cash and Opioids don't mix. Even if all you are offering is injections and spine/sports you'll be on the radar. No thanks

Why would you be on the radar for cash pay procedures?

 

[Centurion38]

Why would you be on the radar for cash pay procedures?

Because you have a pain medicine certificate, a DEA license and are considered "pain management" by everyone except your friends and family

 

[avalon10]

I guess you bring up a valid point. I still see it as a rip off and a waste of money bit if wealthier folks wish to pay more they should have at it. My business models are the complete opposite as I like to operate like Walmart.

Why would someone pay more? Better quality? I guess it's a possibility. I'd like to think I'm the best at LESI but after a few thousand, do providers really differ? I think an interesting psychology develops in certain people when prices go up. Some people assume if they pay more they're getting a better product, such as what happened with Peleton.

I am not saying that it is a better quality injection or doctor or whatever. I am saying that the patient believes that it is. Marketing and hand-holding play a very large role in these kinds of practices.

 

[drusso]

Realize that people with high deductible health plans are defacto "cash patients."

If you're going to discriminate against people who want to pay for their own health care with cash, please be consistent and discriminate against people with high deductible health plans too.

 

[avalon10]

But why "no thanks"??
Everyone has a DEA and certificate. Your comment implies that for some reason a cash-only procedural practice would make you "more on the radar"

 

[avalon10]

Realize that people with high deductible health plans are defacto "cash patients."

If you're going to discriminate against people who want to pay for their own health care with cash, please be consistent and discriminate against people with high deductible health plans too.

There is no discrimination involved at all. Why would you use such an inflammatory word?!?
People are free to run whatever kinds of practices they choose to. Is the cash-only plastic surgeon discriminatory?!?
It's not up to you to decide what kinds of patients someone else takes. Feel free to run your own business the way you want to, but why don't you save judgment.

 

[drusso]

There is no discrimination involved at all. Why would you use such an inflammatory word?!?
People are free to run whatever kinds of practices they choose to. Is the cash-only plastic surgeon discriminatory?!?
It's not up to you to decide what kinds of patients someone else takes. Feel free to run your own business the way you want to, but why don't you save judgment.

If you're economically credentialing patients based upon their method of payment, you're discriminating.

People have given their lives on the battlefield so YOU can discriminate against patients based upon service and method of payment. Health care is not a right.

 

[NJPAIN]

To some extent, “you get what you pay for” holds true in nearly everything. You can stay at Motel 6 or the Ritz-Carlton. Both are beds in a room. Motel 6 you get nothing but a bed in a room. The Ritz-Carlton you get your bed and hopefully some personalized service. At the Ritz you have an issue to address and the General Manager gets on the telephone. At Motel 6 the desk clerk laughs in your face. Some people can and will pay for what the Ritz offers. You may think it’s a waste of money.

In medical care some people can and will pay more for more personalized service. It’s not hotel level $100 vs $600, it may be thousands. It’s no more of a ripoff than a fancy hotel. If the Ritz doesn’t live up to your expectations you don’t go back. In today’s employed wRVU doc model the suits want us to think that all medical care is equal and that you as a physician have no additional value over anyone else. They have done a great job of convincing us of this. A REALLY great job.

 

[avalon10]

If you're economically credentialing patients based upon their method of payment, you're discriminating.

People have given their lives on the battlefield so YOU can discriminate against patients based upon service and method of payment. Health care is not a right.

So every doctor should accept all patients regardless of their ability/inability to pay, their insurance plan, etc?? Otherwise they are practicing discrimination??
That's not how things work in the real world. Healthcare is a business.

 

[avalon10]

To some extent, “you get what you pay for” holds true in nearly everything. You can stay at Motel 6 or the Ritz-Carlton. Both are beds in a room. Motel 6 you get nothing but a bed in a room. The Ritz-Carlton you get your bed and hopefully some personalized service. At the Ritz you have an issue to address and the General Manager gets on the telephone. At Motel 6 the desk clerk laughs in your face. Some people can and will pay for what the Ritz offers. You may think it’s a waste of money.

In medical care some people can and will pay more for more personalized service. It’s not hotel level $100 vs $600, it may be thousands. It’s no more of a ripoff than a fancy hotel. If the Ritz doesn’t live up to your expectations you don’t go back. In today’s employed wRVU doc model the suits want us to think that all medical care is equal and that you as a physician have no additional value over anyone else. They have done a great job of convincing us of this. A REALLY great job.

Agree 100%.
However, the Ritz-Carlton is definitely not what it used to be.

 

[drusso]

To some extent, “you get what you pay for” holds true in nearly everything. You can stay at Motel 6 or the Ritz-Carlton. Both are beds in a room. Motel 6 you get nothing but a bed in a room. The Ritz-Carlton you get your bed and hopefully some personalized service. At the Ritz you have an issue to address and the General Manager gets on the telephone. At Motel 6 the desk clerk laughs in your face. Some people can and will pay for what the Ritz offers. You may think it’s a waste of money.

In medical care some people can and will pay more for more personalized service. It’s not hotel level $100 vs $600, it may be thousands. It’s no more of a ripoff than a fancy hotel. If the Ritz doesn’t live up to your expectations you don’t go back. In today’s employed wRVU doc model the suits want us to think that all medical care is equal and that you as a physician have no additional value over anyone else. They have done a great job of convincing us of this. A REALLY great job.

I trained at Mayo and remember rounding on the cash-pay international patients on the VIP floors and thinking to myself, "I want to dedicate my life to helping people who can afford this."

The Suites at Saint Marys - Mayo Clinic

www.mayoclinic.org

 

[drusso]

So every doctor should accept all patients regardless of their ability/inability to pay, their insurance plan, etc?? Otherwise they are practicing discrimination??
That's not how things work in the real world. Healthcare is a business.

No, I'm arguing for equitable discrimination.