Thinking of starting a cash-based practice? Here are the pros and cons.


As an integrative medicine physician, I am often questioned about what I do and how I decided to diverge from the normalcy of allopathic medicine. I usually go into a short spiel about my love for thinking outside the box and creating solutions for patients that seek a kinder, gentler style of medicine; one that blends effective healing modalities from all over the globe with my traditional allopathic training.

Most people enjoy this explanation and inquire more into my practice. Others shy away.  But the most frequent question I get after this explanation is if I take insurance in practice. The answer is a resounding “no.”

Do I not take insurance because I’m a mean and vengeful physician? As it is, families pay an exorbitant amount of money for health insurance with the added load of high deductibles straining their budgets.

I get this as, I too, am a consumer of health insurance and know first hand that it is not cheap!

However, what the masses may not understand about being a physician is the hefty price doctors who take insurance pay.

Through research, we have learned that approximately 50 percent of physicians feel distraught or distressed at work on a regular basis and many others have left medicine for other careers, or even worse, committed suicide. Others have opted out of insurance by converting to concierge medicine or direct primary care (DPC) clinics.

Could the doctors leaving the insurance-based system possibly be standing up for themselves and their profession by not taking insurance? I argue yes!

Here’s how:

Self-employed doctors can make more. As a cash-only physician, it is possible to charge what you believe your services are worth. If you believe you are worth $350 an hour versus the $250 insurance may reimburse you at for an hours worth of work, you can charge that much and discount your services as needed. No hassle and no arguing to be paid what you deserve! Plus, you don’t have to hire anyone to argue with the insurance companies to be paid.

Entrepreneurship is fun. When you are a cash-only business, you become your own boss. You no longer have to appease administrators nor pay their lofty salaries in this model. Additionally, you get to be as creative or uncreative as you want to be. Want to offer a promotional special or hire a physical therapist part-time to work with your patients? Great! You make the decisions!

You will be free of writing notes to satisfy insurance companies. This is actually my most favorite part about not taking insurance. I used to spend about 16 hours/week documenting my notes to submit to insurance companies. Making sure I incorporated all of the necessary parts of the note (which are mostly insignificant to medical providers), took place in my free time, during lunch and after clinic and it lead to significant burnout.

But no longer! I can write my notes in a way that is useful to me without any rules or restrictions. I can’t even tell you how freeing it is to complete a note shortly after seeing a patient and never having to think about whether or not I checked off enough boxes to get paid.

You can spend more time with patients and truly facilitate change. Another favorite perk! You decide how long to spend with patients and no longer have to shoo them out the door after 15 minutes. Yes, there will always be issues that come up with patients that will take longer to address than expected, but, you can now charge for time and get paid accordingly (similar to how an accountant, mechanic or lawyer charges).

Cash-based medical practices bring transparency to medicine. As a cash-based physician, you no longer have to battle with insurance companies to get paid, nor does the payment model change arbitrarily at the companies’ whims. As a patient, you know exactly how much you’re going to be charged and don’t have to worry about getting a bill from your insurance company later on. I think we can all argue that more price transparency is needed in medicine!

The drawbacks to a cash-based practice include:

The cost to patients/consumers. This is the most mentioned argument I hear from people as to why they do not want to switch to a cash-based practice. Most Americans are paying for medical insurance and it is not cheap. Thus, many people are reluctant to spend more money on their health by seeing someone outside the insurance system.

The way I see it, though, is that people put money into things they prioritize. Injecting insulin 3 to 6 times a day can be extremely costly. My goal is to prevent the use of insulin, thus shifting the cost-savings on to my patients.

Patients on federal assistance cannot be seen in this model.As a long time proponent and advocate for social justice issues, it deeply saddens me to have learned through my research that those on Medicaid or disability programs cannot be seen for cash by medical providers for medical care. Most of these people do not have the financial means to seek alternative types of care. Thus, they are seen in large community clinics with overworked providers and limited resources.

Having worked in a Federally Qualified Health Center (FQHC) and state-funded institutions most of my career, I feel this loss deeply. Not only do patients on government assistance NEED longer visit times with their providers, they also need grounded, creative thinkers who use evidence-based solutions to their complex medical and psychosocial problems.

Running a business can be challenging. We all know that the majority of doctors do not make great business people and we get very little “schooling” in business through our training. This does make for stressful times when starting a new practice. However, when surrounded by the right people, anything is possible and the public wants longer appointment times and less hassle at the doctor’s office.

In summary, starting a cash practice is one solution to the crisis of physician exhaustion. And for me, it was a necessity.

I had to leave the comfortable confines of my salaried practice in order to become the doctor I’d always dreamed of being. The doctor who is centered, grounded and wise. The doctor who gets to spend however much time she/he needs with a patient in order to get to the root cause of health issues; the doctor who thrives in her work and in her personal life.

I no longer subscribe to the belief that I am a martyr or slave. And with a cash-based practice, I no longer have to be.

May you all find the medical model that works best for you and your patients,

Ashley Maltz is an integrative medicine physician and can be reached on her self-titled site, Ashley Maltz, MD, MPH.

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