I am an orthopedic surgeon, and I only take cash. When I tell people this, it usually conjures up images of some money-grubbing doctor eager to make a dollar any way they can. Personally, I am not incredibly incentivized by money in and of itself. I try to live a reasonable lifestyle and keep my expenses under control. I started a cash-only practice not for the love of money but for hatred of insurance.

I can tell you what I don’t want to do. I don’t want to mill through 50 patients a day, mindlessly clicking through EMR checkboxes so an insurance auditor five states away will deem that I’ve done my job and deserve reimbursement. That’s a high volume, high overhead game, and I don’t want to play it. I recently spoke with a doctor who was getting so many insurance denials that they needed to hire 14 additional billers at an estimated cost of somewhere around half a million dollars a year. Insurance companies want to make it difficult for doctors to get paid. They will only add more hoops to jump through, meaning that I need to hire more hoop jumpers as a doctor. Hiring hoop jumpers costs a lot of money, which means I need to see more patients. Seeing more patients in the same amount of time leads to shorter visits and worse care. Not to mention the pressure from hospital administrators to “expand your indications,” or in layman’s terms, operate on someone who may not really need it.

So I let it all go. No coders, no billers, no insurance companies, no clunky EMR. It’s only my patients and me. I am providing much better care, not because I am a better doctor than I once was, but because I get to spend more time with each of my patients. It is not uncommon for me to spend up to an hour with each one. It is not the doctors who are flawed, it is the business model of healthcare delivery that we have. Imagine if someone asked you to paint a wall in 15 minutes. You may be able to do it, but you likely would not be able to do a good job. I think it is the same with medicine. I truly believe that by compressing medical visits down to such a short period of time, you must lose quality. There is no time for patient education. That is not for me.

So how do you make a cash practice work? By cash, I really mean non-insurance forms of payments. By not dealing with insurance companies, you do not need the excessive amount of overhead required to receive payments from them. Over time this overhead will only increase, and reimbursements will only go down. Cash payments can be as simple as a patient paying me after I see them, up to the complexity of employer-based contracting. Medicolegal record reviews and independent medical exams can also be a good source of cash-based payments. The reality is that there is no perfect solution for everyone looking to get into this model. I am still figuring out what works and what does not as an orthopedic surgeon. Direct primary care doctors have figured it out, and have managed to create a model that provides excellent care at a low cost. Direct primary care doctors are also generally the happiest doctors I have come across. I think most doctors can find a way to make it work. It just takes some creativity, the ability to take risk, and some luck.

Daniel Paull is an orthopedic surgeon.

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