There are a lot of people who consider health insurance to be a necessary evil.
Insurance and government health programs and can be expensive and frustrating to use for both consumers and providers. However, when patients need medical care, they’re generally glad they’re insured. One of the first questions patients often ask is “Will my insurance cover this?”
At this point you might be saying something like my adolescent daughters used to say to me, ” Duh dad, everybody knows that.” Well, maybe because everybody knows it we are blinded to how much healthcare economics have changed.
One tactic of healthcare reform is to reduce total healthcare spending by shifting upfront costs to consumers. Yet many clinics still think because patients have insurance their practice isn’t functioning as a cash practice until deductibles are met.
Dependency on the insurance cash cow can lead to ignoring the tens of millions of Americans who are either uninsured, have high-deductible health insurance, or just want to escape from bureaucratic medicine all together. There are thousand of consumers who want healthcare without an insurance company’s or governmental involvement. They reserve the right to choose their preferred provider with no outstide influence.
There are therapists who are bypassing insurance all together too.
Therapists are setting up cash-only practices with the goals of spending more time with their patients and taking back financial control over their livelihoods. They cater to consumers who are looking for affordable medical care and expect to pay out of their own pocket for some or all of their healthcare.
Now the question is not ‘Will my insurance cover this?’ but ‘Whom can I trust to give me the best care for my money?’
This is where a cash practices makes the most sense. A cash practice is built from the ground up to serve self-pay consumers. As mentioned before until deductibles are met patients are essentially paying cash for the care they received.
The cash practice model comes in several names and forms. It’s sometimes known as self-pay, cash only or concierge medicine. Cash practices among therapy entrepreneurs are not a fad.
We are starting to see more self-pay clinics among primary care doctors too and there are some specialists are going this way, too. The growing trend of medical practices catering to self-pay patients is in direct response to economical and cultural shifts in the United States.
What are the big benefits for therapists?
Therapists leave the traditional insurance-based payments for the cash pay model for variety of reasons. Here are a couple of the main ones:
1. Tired of the churn
Many therapists are fed up with factory-like therapy with its over emphasis on production and profit.
2. Frustrated with bureaucracty
PTs and OTs have grown tired of dealing with the bureaucracy of insurance. The endless stream of paperwork to comply with over reaching regulations has caused many therapists to look for different practice options.
3. Feel undervalued
Therapists are tired of fighting to get paid for what they feel they are worth. They see insurance payments for patient treatments as being ridiculously low. At the same time they see their operating costs rising. The only solution some therapists feel is to work faster and see more patients,
4. Compromise quality
Therapists are seeking alternatives because they feel they are compromising the quality of the care and their professional self-respect.
5. Loss of freedom
Everywhere therapists turn outside forces are telling them what they can and can’t do. Increased regulations and employer productivity demands are stiffling therapist’s growth and freedom. Not just their professional work but their personal lives as well.
“I’m mad as hell and I’m not going to take it anymore”
Therapist’s angst reminds me of the 70’s movie Network where newscaster, Howard Beale yells into the camera and tells his viewers to get up out of their chairs, go to an open window and yell “I’m mad as hell and I’m not going to take it anymore”.
Therapists all over the country have reached their breaking point. They are not going to take abuse from the insurance system anymore. They are mad as hell and they are going off the insurance grid.
That’s all good and well for therapists but we haven’t answered our initial question.
Are cash practices good for patients?
Cash-based practices can be a good investment, even for patients with insurance. Contractual requirements from corporate health plans have intruded into the medical provider-patient relationship. Obamacare with its more than 132,000 pages of regulations has added even more layers of red tape creating a bigger wedge between therapists and patients.
Patients experience this wedge when they have to fill out more forms and provide more personal information. They feel it when sitting in waiting rooms much longer than they do in front of a physician. They experience less time with the primary care providers before they are passed on to supportive personnel. They know they are paying more but getting far less.
What are the big benefits for patients?
1. Cost effective care
Therapists have the extensive education and training to be neuromuscular primary care experts. For the majority of patients’ with movement problems therapists are the provider of choice. For people with high deductibles, it makes financial sense to pay a therapist for a comprehensive evaluation and treatment.
Fifty percent of Americans will experience some type of musculoskeletal episode each year. Skilled cash based therapists are a third-party-free alternative for self-pay patients.
In most states therapists have direct access. Patients typically have a shorter wait times in a cash practice. Most clinical prediction rules state that the sooner the patient is seen the better the outcome.
Let’s face it, patients are becoming impatient driving around town, filling out insurance forms wherever they go. The busier they are the less tolerate they become with poor customer service.
3. Transparent Affordable Pricing
For the self-pay patient finding therapists who offers fair, simple and transparent prices is crucial. Cash based pricing eliminates the added administrative costs when submitting claims to insurance companies. No more “We’ll send to insurance and see what they pay” when both parties know that the charges are coming out of the patient’s pocket.
4. Protected Patient-Therapist Relationship
Imagine a practice where that doesn’t demand your insurance card and ID before they say hello. Imagine a practice where money doesn’t get in the way of patients getting to know their therapist.
Taking insurance middlemen out of the equation allows therapists to present themselves as an empathic professional who understands the true cost of healthcare.
5. All Patients Are Welcome
All patients, insured or uninsured, in network or out-of-network are welcome. Payment is by cash, check or charge. Patients aren’t rejected because of their insurance carrier. Cash practices that are designed for self-pay patients are free from outside interference to address the circumstances and needs of individual patients.
The cash practice alternative seems to satisfy a growing appetite among consumers, especially those who are under 65 and not on Medicare. Today’s healthcare consumer has become embolden to know what care cost and are demanding more transparent pricing.
Just like they do in every other area of their purchasing lives they search online, compare, asks their friends before making a wise purchase.
There is a growing intolerance towards the hidden cost of healthcare. Practices that change their billing practices from the ground up to accommodate the self-pay client will be better prepared for the next generation of healthcare consumers.
My final question for you. I’d love to hear your viewpoint in the comments or on social media.
Are you so hung up in traditional third party reimbursement that you aren’t doing what’s best for your patients?
Paul Potter is a physical therapist and mentor who lives in Lincoln, Nebraska, with his wife, who is also a therapist. They have four daughters. For more than 35 years he successfully managed his own private practice.
He has authored On Fire: Ignite Your Passion with a Cash Therapy Practice and Cash Therapy Practice: Professional Freedom in the New Healthcare Economy. His website PaulPotterpt.com and his podcast Functional Freedom are dedicated to helping therapists build their dream practices. Connect with Paul on his website or on Twitter @lifetouchpt. You can also get more free resources at PaulPotterPT.com
Commented September 11, 2018
Commented September 10, 2018
I would like to believe there is room for qualified Speech Language Pathologists to provide evidence based theraputic intervention along side PT's & OT's.
Commented December 31, 2016
James, I've read through the post a couple of times. What verbiage were you referring to?
Commented December 31, 2016
Chiropractors are physician status in every state. Therefore WE can diagnose and treat medical problems. The DC scope is greater than the PT or DPT scope. Please beware your verbiage.
Commented September 20, 2016
Jennifer, I appreciate you joining the conversation and thanks for being a pacesetter with your leadership at Body Dynamics. It looks like you've scaled way beyond one to one with your group classes. If you have a moment, would you mind sharing how you envision therapists might scale even beyond classes? I'm thinking about the use of technology like telemedicine, online videos/courses, apps for home exercise or fitness programs etc. Keep up the great work. Thanks
Allison Suran, PT, GCFP, TPS
Commented September 20, 2016
Thanks Paul; I believe in Oregon Medicaid covers dental (ie; root canal) and I've met people who have had to just have their teeth pulled as it's cheaper than trying to save them-- which they can't afford. Yes, "never" is a strong word, and I do believe that many if not most of the folks I serve would never be able to figure out how to pay for my services especially when they have coverage by insurance. And, once in a while I notice that someone with little to no financial "means" finds a way to pay for something holistic out-of-pocket. In spite of my huge frustrations with dealing within the system, for now, it is the path that is most appropriate for me and the people I serve.
Commented September 19, 2016
Paul and David, Happy to join this conversation, as I have been running a successful Center for Sustainable Health for over 20 years. David, you are spot on with scalability...and yet that is what the health system needs. Is scalability only defined by the number of clinics a single entity owns, or can we do it using the uber/Airbnb model. I think the latter. We just need to bring some structure to it.
Commented September 16, 2016
David, congrats on taking the dive to start your own PT/wellness clinic. I admire your courage. I was able to live my dream of a wellness/clinic too. It was a great ride. Here's a few of my thoughts in response to your insights. APTA's Private Practice Section average clinic size is 1.3 clinics. There are only 6 million active businesses in the United States with one or more employees. 3.8 of those have four or fewer employees and another million with five to nine employees. I don't know how far up the scale an enterprise is but for the most part I'm speaking to average therapists in small business. Second observation. Next weekend I'm speaking at Nitin Chodda's Ignition 2016 conference. Nitin has scaled his practice/business through EMR software, books, consulting, coaching etc. I'm going to use Uber to get from the airport to the Airbnb where I'm staying. Five years ago I wouldn't have been able to even imagine individuals using their own car and apartment to provide services at an competitive price. Uber and Airbnb innovatively provided solutions to meet a consumer need where it didn't exist before. Perhaps I'll be reading some day about David Self creating a way for consumers to pay cash for therapy and turning it into a international successful enterprise. You heard it hear first.
Commented September 16, 2016
Allison, thanks for your thoughtful comments. By the looks of your website you offer a variety of integrative services and learning opportunities for people to rise above their pain. Well done. The chronic pain population is certainly underserved. I have a certification from the International Spine and Pain Institute. They are doing a wonderful work on making the latest neuroscience research available to clinicians. The clinic that I work part time in accepts patients from the local free health clinics and sees patients at a local correctional facility. We are familiar with needs of the poor among us. We are committed to caring for the underserved as you are. I don't have pat answer to the points you bring up other than I'm committed to finding a way. Unfortunately, I don't see any indications from CMS or other insurance companies of the administrative burden lessening. Your word NEVER is a big word. I wonder if we might think about our services in this way? Do any of our patients pay out of pocket for dental services to relieve tooth pain? The average cost of a root cannal is about $1,000. If any our patients don't have dental insurance do they forgo the root canal and live with the pain? Or do they pay cash? It seems the ADA's decision 30 years ago to practice outside by in large outside the insurance system was a wise move. Is it too late for therapists to follow their example? I think not.
Commented September 16, 2016
Thanks for the post Paul. One of the other points that I think is important to ask is: how big of a story do you want to write? My personal opinion is that cash-based PT is difficult to scale, particularly at an enterprise level unless it is packaged in an immersive "lifestyle" clinic and/or workplace wellness. We see this in the market today in a variety of places, such as Body Dynamics in Virginia, Physiologic in NYC, and even to a certain extent Equinox (although not PT, I mention because customers go to Equinox for high-performance living, not to "workout"). If you look at the cash-based landscape, you have two types of people in my observation. The first is the clinic owner that has one, maybe two clinics. The second is the owner that has one, maybe two clinics but is a content marketer and influencer in the cash-based world. I'm sure I'm oversimplifying this, but by and large this seems to be the current state of the market. I'm not familiar with any siloed cash-based PT company that has 10, 20, 30 plus locations. Of course, this isn't necessarily a downside - it just depends on what you're inspired to do. I'm personally interested in the enterprise scalability of alternative payment models, and I've grown to believe it is perhaps best executed via allied care integration with primary and secondary prevention providers. Cheers guys. *As context, I started my own wellness plus PT clinic as a new grad.*
Allison Suran, PT, GCFP, TPS
Commented September 16, 2016
I've been watching this post to see what the comments are. I've had a small-ish PT clinic in Bend Oregon for 18 years and have my own bias towards continuing to do my best to accept most insurances despite the huge administrative burden. in Bend, OR we supposedly have 3x more PT's in our town than anywhere else in Oregon -- because it's an awesome place to live -- so I can't imagine why someone would cash-pay when they could use their ins. Although I could leave my practice and employees and see patients privately on my own, as I've advanced my skills over the past 30 years to specialize in chronic pain, I am committed to seeing the vast majority of patients who could NEVER consider out of pocket payment. Of course, most of these are Medicare and Medicaid, though several have commercial insurances. I suppose there are chronic pain patients who somehow have managed to have financial resources available for cash-pay, but it would be a very low percentage of my current clientele. I would prefer that our profession (APTA) work on making our reimbursement worth all of the administrative burden rather than us encouraging one another to make ourselves inaccessible to the poorest among us. It's easy to not recognize the poorer people in our community if they don't have access to you - - then you just don't have to recognize how difficult some peoples lives are. Of course cash-pay is an appropriate option for some, but it doesn't solve the challenge of an increasingly complicated health-care system which continues to create obstacles for optimal health for the less financially secure.
Commented September 15, 2016
You're welcome Judy. Congrats on launching your own practice, I admire your courage. Now is a great time to start a PT practice. It looks so different from when I started mine many years ago but there are so many resources available to help you get your practice off the ground. I intend to write more on this topic for entrepreneurs like yourself. Stay tuned and let me know what helps you the most.
Commented September 15, 2016
As someone who just started her own cash-based private practice, I could not appreciate this post more. You bring up such great points! Thank you.
Commented September 14, 2016
Jessica, One of the joys of contributing to the EIM community is reading comments such as yours. Your description of patients seeking alternative healers is very articulate and spot on. Thanks for your contribution. I thought your summary sentence "If only these patients were able to receive excellent, evidence-based PT care that was delivered with empathy AND a commitment to fostering self-care/empowerment…that would truly be the win people are looking for and are willing to pay out of pocket for." points us towards the direction our profession needs to go. I believe physical and occupational therapists are uniquely qualified to fill this space in the present healthcare system. It's up to us if we have the courage and will to move into it for the good of our patients and society. Keep up the labor of love.
Commented September 13, 2016
Great post, Paul! As a direct-pay practice owner, I echo all of your pros for patients, and would add another phenomenon that I have observed: There is a whole group of patients that are currently being "missed" by mainstream PT and mainstream medicine in general. You mentioned the uninsured, those with high deductibles, and those who are frustrated with insurance red-tape. These folks are great candidates for direct-pay PT and I have found them extremely appreciative of the cash model. However, there is also a group of patients out there that are currently seeking, receiving, and already paying out of pocket for care...a lot of care. They are frequenting massage therapists, chiropractors, acupuncturists, and other "alternative" healers, sometimes with alarming frequency and sometimes for issues that actually NEED medical intervention. Unfortunately, many of these patients are seeking help from outside the system because they have become suspicious of mainstream medicine. They suspect that mainstream health care is all about the almighty dollar and that MDs are puppets for drug companies. As you mentioned, they are tired of lengthy waiting lists and brief encounters with MDs, PTs, etc. But more importantly, they feel unheard, disregarded, and shuffled from one specialist to another, and often assume it is all in an effort to line the pockets of "the system." They have given up on a system of the fragmented care, where no one seems to want to take them on with the level of commitment they are seeking. This is what they find in the alternative professional, and they like it. They LOVE it. The unfortunate part of this equation is that the patient then often falls into a lengthy (sometimes life-long), PASSIVE treatment regimen which, over time, costs them thousands and thousands of dollars. They begin to believe pseudo-science and elevate their practitioners' opinion above sound evidence and practice guidelines. We have all heard horror stories of patients who continued receiving months of care from "alternative" practitioners, all the while their cancer was spreading and very likely would have been identified as suspicious if only they had been seen by someone with the background to identify red flags. If only these patients were able to receive excellent, evidence-based PT care that was delivered with empathy AND a commitment to fostering self-care/empowerment...that would truly be the win people are looking for and are willing to pay out of pocket for. Direct-pay PTs have a great opportunity to bridge the gap between those who have wandered far from the mainstream (after all, sometimes patients NEED that diagnostic test, and they need someone with the differential diagnosis skills to point them in that direction). Our commitment to maintaining relationships with other medical professionals, referring when needed, and delivering sound, evidence-based treatment places us in a very important niche for not only great patient care, but also for enhancing public safety.