Cash Only

[jmj11]

I've racked my brain looking for a doable model for a small independent practice.  Cash only has often been suggested. I attended a webinar this week end with a focus on small practices surviving under the ACA.  One point made by a MD (who mostly does lectures on economics now) and is a self-proclaimed expert on ACA, said it would be impossible to be a cash practice by the year 2018 per the mandates, but probably not even by 2017.  I've read a lot of the law but not all of it.  Anyone else heard this?

[SocialMedicine]

I do not see small primary care practices existing in 20 years. every year the number declines. Honestly, given the work load of primary care, it is robably better to have larger entities who can provide more services for patients.

 

Specialty clinics are another story. I think they will still exist in some form.

 

With more and more people becoming insured I see less of a pool of working people (or people with wealth to spend on medicine) looking for cash medical services. However, if you are offerring something top of the line or not covered by health insurance you may still have an in. For example, one medical group is all over the US now. They charge an annual cash fee to be a member of the medical home. They offer designer medical offices with enhanced use of technology and communication. The service is not for everyone but clearly the business model is working given this one company success. Why would I pay 100$ to see one HA specialist when my insurance pays for another down the block ? But if you are the only show in town and offer something unique that patients will find enticing then it could work.

 

There is a big push for PAs to own practices. I agree with that push today. But if the plan to enact those laws are a ten year agenda then it is not worth the cost. The small private practice is coming to an end in my opinion.

[jmj11]

I agree that the small practice is an endagangered species.  Insurance companies, in the wake of ACA are burtal to small practices.  We are having to find a way to restructure now.  To survive I must add several new providers, combine with another practice or join a large group. The problem with goining a large system, which is uniuqe to headache work, is that headache disorders and the treatment there of is the most misunderstood discriminated against illness.  Large systems don't get it and will always enforce inferior care for headache patients, which I don't find acceptable.

[ventana]

think this has to do with HAVING to be a part of PECOS and Medicare to order absolutely anything.....  

[SHU-CH]

 Large systems don't get it and will always enforce inferior care for headache patients, which I don't find acceptable.

 

That's my concern with nationalized healthcare - there is no larger system than Uncle Sam. 

[CAAdmission]

There is a video somewhere on Youtube of three docs that went off the grid, cash only, buy meds in bulk and run their own dispensary. They enjoy life. If I find the link I will post it.

[out_foxed]

Ok I found a 2015 document that references MD oriented cash only or concierge care. It does in fact mention the Affordable Care Act "may potentially reduce the number of physicians shifting toward cash-based and concierge medicine".  Some anecdotal info, but looking at the references may lead to some where useful. 

 

Disclaimer that I am applying for PA school this year, I've worked in medical billing x-ray, clinic and hospital care; I don't know what i'm talking about, but I understand what i'm talking about.  But depending on the ACA's mandates for insurance and other limitations, isn't it agreeable to say a cash only practice would be MORE viable under the direction and employment of P.A.s?  I would guess this is true based on overhead costs alone. 

 

But the elephant in the room is mandated insurance requirements for both the patient and the provider (& facility).  Think tank moment: Is it viable to add a co-pay/service minimum that would act a as a semi-concierge model, a hybrid model, sorry for the buzz word.  Our urgent care clinic requires $75 upfront with out insurance, that helps balance out the delinquent accounts. 

 

Here's an interesting (probably semi- statistically valid) info graphic about concierge care http://www.medicalpracticeinsider.com/news/concierge-care-really-good-deal-doctors

 

Keep talking folks this is interesting.  And depending on whether P.A.s are going independent in the future or not will have an effect too. 

[jmj11]

I'm looking at four possible ways forward for us.  One of those ways is a hybrid practice. Now, 5% are Canadians who pay cash. But this idea would be drastically reducing our overhead, accepting only the top 5 insurances via reimbursement, and then cash-only for the rest. I could survive on 5 patient encounters per day rather than 18 per day, if the providers were the only people in the office and we didn't have to deal with insurance companies.

[julia_dodo]

I recently found an interesting talk by a certain Dr. Pamela Wimble. Her idea is basically what you have mentioned, jmj11--if providers were the only people in the office we can reduce overhead drastically. If anyone is interested, check out her website. I don't know how things are going to turn out but it sounds like a good idea to me. much smaller population, more concentrated care, better quality care overall, AND less stressful. 

ACA is not going very well. more and more people are complaining and cannot find affordable insurance plan under the affordable care act--isn't that ironic? A lot of people I know simply said they would rather pay the fine than getting expensive insurance. Even a lot of people with insurance, their deductibles are so high that they would never use it up unless they get really sick. In that case whenever they go to a clinic, effectively they are still paying cash price. 

So what if you start a cash clinic but charge a little less? say $50 instead of $100 per office visit? Those people with high deductibles may just choose your practice vs. their PCP.

[sas5814]

I am a little late to this conversation but I am getting ready to open my own clinic in a few weeks. It is interesting that consolidation is such a thing now and the imminent death of the primary care clinic being foretold in many circles. I suspect it will be true in many areas but there are still vast areas of the US that simply cannot sustain a large multi specialty type clinic and never will. I have watched huge groups and hospital organizations try to send specialists into these markets even part time and it just doesn't work because of the number of people involved and how much each person and entity tries to squeeze out of the system. These more rural areas will always need some kind of care close to home and that is going to be my niche. I live in a rural area and my town, with a population of plus or minus 10k is larger than many of the towns around. I think there will always be a market in smaller less populated areas for small lean primary care practices. Once this clinic starts making a few dollars I will be looking to open others in similar circumstances. I'm also making a hybrid type practice. We will take Medicare and most major insurances, may take some limited Medicaid (there is a way to see sick people without getting into all the childhood immunizations etc which is a huge pain) and will have a cash schedule for people who would just rather pay than use their insurance (with the understanding the cannot file it on their insurance). I will also be doing some cash-only services like weight loss, alternative hormone therapies, and maybe eventually some cosmetic type stuff. I think by being in the right place, with the right prices and services, and the right mix of payers and cash I can be very successful....particularly since it it just me and a staff of 2.

[jmj11]

Good luck to you and I hope you have a great success.

[JohnnyM2]

Much of this discussion assumes the unAffordable Care Act survives into 2018, and it very well might, but I hope, and will vote, for a different outcome. Many of your posts suggest some patients may gravitate towards a market based practice. Imagine if patients had some control over their health care dollars and had the freedom to choose the care they want and need. I can testify that a lot of my health care dollars are completely wasted because tests and scans that are unlikely to change diagnosis or care are paid for, so I don't argue. I would like to have a bucket of health care dollars that I control and catastrophic insurance to provide a safety net. My health care expenditures would be very different.

Getting back to the topic, the kinds of PA owned and operated clinics some of you are discussing would be great solutions in a market based health care economy and would likely thrive. I would really like to see that.

[ventana]

I am a little late to this conversation but I am getting ready to open my own clinic in a few weeks. It is interesting that consolidation is such a thing now and the imminent death of the primary care clinic being foretold in many circles. I suspect it will be true in many areas but there are still vast areas of the US that simply cannot sustain a large multi specialty type clinic and never will. I have watched huge groups and hospital organizations try to send specialists into these markets even part time and it just doesn't work because of the number of people involved and how much each person and entity tries to squeeze out of the system. These more rural areas will always need some kind of care close to home and that is going to be my niche. I live in a rural area and my town, with a population of plus or minus 10k is larger than many of the towns around. I think there will always be a market in smaller less populated areas for small lean primary care practices. Once this clinic starts making a few dollars I will be looking to open others in similar circumstances. I'm also making a hybrid type practice. We will take Medicare and most major insurances, may take some limited Medicaid (there is a way to see sick people without getting into all the childhood immunizations etc which is a huge pain) and will have a cash schedule for people who would just rather pay than use their insurance (with the understanding the cannot file it on their insurance). I will also be doing some cash-only services like weight loss, alternative hormone therapies, and maybe eventually some cosmetic type stuff. I think by being in the right place, with the right prices and services, and the right mix of payers and cash I can be very successful....particularly since it it just me and a staff of 2.

 

Don't bother with poor paying insurance

 

You will loose money to see these patients, then loose more money chasing payment, then loose more money with no shows.....

 

If you want to be in business you have to make enough money to pay the bills and stay in business. In order to do this you MUST maximize income and limit expenses. This goes against the 'helping everyone inspite of ability to pay" and against a new business "take any comers. BUT yo will regret getting overwhelmed with patients that do nothing but cost you time and $$$

 

 

If you want to be successful and practice great medicine you must be paid!

[GetMeOuttaThisMess]

We have developed an interesting model in my gov't. related practice. We're snot/cough/UTI/rash only. I'm amazed at the volume for such a limited scope and yet with a minimum co-pay ($10) we have saved the employer over $500K in just a tad over six months, and that includes two providers with a skeletal staff of five others. No insurance filed. No serious flu season. No after hours/weekend coverage. Our collaborating docs are part of a ginormous blended network here in Texas and any concerns can be farmed out to one of their clinics. I think this will continue to be a trend amongst businesses or gov't agencies. Cheaper for employers to cover us than pay exorbitant health premiums (emp./dependents who are not required to be covered in one of several health ins. options).