As the insurance-based model of health care becomes increasingly unsustainable for physicians and patients alike, more clinicians are opting out of insurance entirely and embracing cash-based models of care such as direct primary care or concierge medicine. However, as this trend grows in popularity, some have questioned the ethics of such a model where those with extra cash or wealth can access better care while those reliant on their insurance only are stuck in an essentially lower tier of health care. As a physician in primary care dealing with the insurance-based system, I would like to voice my support for cash-based physicians and explain why their work is not only ethical but a necessary means to fight back against corrupt insurance companies and abide by our oath to give good care.
First, let’s delve into what insurance has done to modern patient care. As insurance continues to drop reimbursements and getting paid by insurance becomes ever more complicated and difficult, more physicians struggle to keep their practices afloat. With lower reimbursements, practices have to reduce visit times and overbook schedules with more patients just to make their overhead or risk going out of business. This means shorter, lower-quality visits for patients or patients simply losing access to care as their doctor’s office shuts down.
Dropping reimbursements aside, just dealing with insurance-related issues such as prior authorizations, finding alternative treatments, peer to peers, denials, and billing requires time from doctors that could be going to patient care, or it requires hiring entire departments to handle these issues, which makes the practice even more difficult to sustain financially. In short, insurance is increasing administrative work load, reducing time with patients, and making practices difficult to sustain financially. On top of all this, despite never having examined the patient or acquired the training and expertise of a physician, insurance companies are dictating care for patients by denying appropriate treatments recommended by their doctors. This has resulted in subpar care for patients. It has also contributed to physician burnout, pushing many clinicians to quit practicing, and worsened the already severe doctor shortage.
Bypassing insurance and running a cash-only practice removes many of these barriers and problems. It allows physicians to give better care based on their expertise and training. It also helps the doctor shortage by reducing physician burnout to keep more in active practice and makes their practices more financially sustainable to keep their doors open. Not only that, but many of us in insurance-based offices are unable to accommodate and see all the patients in our communities as there are so few of us. Patients are waiting months or driving hours to see certain doctors as there are not enough to go around. If even a few patients from insurance-based offices move over to a cash-based practice, it opens up visit slots for other patients who would not be able to see a doctor otherwise.
Of course, I will address the elephant in the room that this may result in a two-tier health system based on wealth. In a sense, this will allow wealthier patients to have better care, when in an ideal world, patients of all economic backgrounds should have access to the best care. However, this stratification of health care access based on wealth already exists with insurance too, as wealthier patients can afford to pay higher premiums for better insurance coverage or pay out of pocket when something is not covered. At least with cash-based practices, some patients have the option to get the care they deserve without the drawbacks associated with insurance. Furthermore, as more patients opt to reduce their insurance coverage and premiums in favor of cash-based practices, insurance companies now face some much-needed competition, which may keep them more accountable.
Cash-based medicine can also be accessible for patients of lower economic backgrounds or even reduce overall costs for patients. Although concierge practices are typically more expensive, many direct primary care offices charge more reasonable monthly or annual fees that many patients can afford. In fact, without insurance leaching money from patients and their physicians, patients may save on reduced insurance premiums and know that the money they do pay in a cash-only practice goes fully to their clinicians and care. Furthermore, patients may see a reduction in their overall health care costs with the added time, attention, availability, and overall improved quality of care associated with cash-based practices.
In cash-based offices, primary doctors can manage more complex issues themselves, reducing the need for referrals or multiple specialist visits. They can also give more effective preventive care, which prevents diseases from progressing or developing entirely. Their added availability may even save patients trips to the ER or urgent care. With the monthly or annual fee system, patients can even have as many doctor visits as they need without worrying about additional copays or paying for each extra visit.
Although cash-based care is not a perfect solution nor one that will fix the health care system entirely, it is certainly an ethical step in the right direction. Insurance and the many other problems in our health care system still exist and must be corrected, but cash-based practices can occur in tandem with that too. It is not a zero-sum game where we must choose one or the other. If anything, taking the cash-based option away and only allowing the subpar, insurance-based status quo is likely more damaging.
What do you think about cash-based care? Share in the comments.
Dr. Shadman Sinha is a general pediatrician practicing in New York. His passions are speaking out about health care reform and educating parents via his many social media accounts. He also loves rocking out on his guitar and playing with his band. He posts regularly on TikTok, Instagram, and Youtube @docshaddymd. He is a 2025–2026 Doximity Op-Med Fellow.
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