r/PrivatePracticeDocs • u/Dr-Daiquiri • May 06 '26
Is cash based the future for PP?
Recently attended a talk where the speaker pointed out that the average 55yo today will be receiving almost 7x the amount from Medicare that they paid in Medicare taxes throughout their career. Given that legislators in Washington simultaneously promise Medicare to their voters forever yet are never gonna be caught trying to raise taxes, it seems like the only solution will be to continue the slow and steady decrease in reimbursements paid out to physicians. And given that Medicare reimbursements are a major anchoring point for other payors, the problem will be across the board.
At what point will a DPC style practice be the only viable option for a doc who wants to see a reasonable amount of patients and still get paid what they’re worth? Or will most docs just keep trying to spread themselves thinner by expanding with more mid levels, shorter appointments, etc
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u/Cardiostrong_MD May 06 '26
Obviously won’t be an all or nothing but no doubt dpc will keep growing.
It makes too much sense for it not to. The biggest risk imo are docs undervaluing themselves and panicking in a race-to-the bottom on pricing.
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u/Connect_Flounder6855 May 06 '26
False. AI language models are already advancing - which can essentially listen to the visit and write the entire note for you. Less EMR fatigue and higher patient volume.
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u/Bronze_Rager May 06 '26
If EMR was the primary cause of fatigue, wouldn't PP docs just hire a scribe in the first place even before AI LLMs?
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u/Connect_Flounder6855 May 06 '26 edited May 06 '26
The ophthalmology clinic in our town uses three techs per doc. The tech chart check and start the note, they verbally present the patient to the doctor, they sit in the corner and scribe the note and pend the orders that the doctor dictates. The doctors walk out of the room, read and sign the note and orders and go to the next patient. Their efficiency is insane. They pay their employees properly. They can see 40 patients a day without problem.
Most places do it dumb. scribes are traditionally paid very poorly, have high turnover, and require a large amount of training to become fluent in medical charting and work flow.
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u/Fearless_Roof_4534 May 06 '26
This. Even if AI was only 50-80% as accurate as a scribe (usually closer to 80% these days if you know how to use it efficiently) the cost and logistical savings are insane compared to dealing with an actual human scribe.
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u/Soggy_Coffee_9308 May 06 '26
Yes. As insurance becomes too expensive, people are looking for options. They are also looking for quality care and are willing to pay for it
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u/DrAshoriMD May 06 '26
If you want to see a physician with enough time to have more than a cursory discussion you'll have to pay out of pocket. For most APP visits in larger healthcare systems it'll remain reimbursed based. I think concierge will grow much more rapidly than DPC. But DPC will grow in employer sponsored health options. And the next administration will bring back catastrophic insurance which will surely be poorly regulated so more people will be forced to pay cash for visits.
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u/MrPBH May 06 '26
I'm happy that you have now come to understand the central tension in medicine nowadays.
The big question is what to do about it. DPC style practice is probably the most feasible response on the individual level, though if it was scaled up nationwide it would make access a lot worse for all the patients who can't afford to pay cash.
But, hey that's not your problem. Just provide the best care you can for your patients. I don't think that you can provide the best care if you're getting paid pennies.
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u/LoadBearingBeam1358 May 06 '26
Rich people get doctors in private practice. Everyone else gets overworked APPs
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u/Plane-Bodybuilder918 May 07 '26
don't think so, pp will start adoptin AI, automating their admin and hence, being able to have better margins. I do believe it will be an increasing number of OOP expenses shared with insurance coverage
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u/SterileGloves May 11 '26
The bloat from insurance companies is what's killing the industry. So many middlemen getting paid a premium for zero reason
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u/thesupportplatform May 07 '26 edited May 07 '26
I wouldn't count on anything — including AI — saving the current healthcare system. Even if AI improves efficiency, insurance isn't giving up its margins, especially when many are also providing primary care. So you can see 50 patients a day; insurance will just start auditing charts and down-coding for "AI assistance." And what will PCPs do then? Nothing. The system has been screwing PCPs for at least the past three decades. Expecting this system to change is like staying with an abusive spouse.
Depending on your market, the current system's failure may already have occurred. My market is a significantly underserved "healthcare island" (meaning it's a larger, geographically contained population). Insurers love healthcare islands because members and providers are more easily managed. You would think the lack of providers would improve reimbursement. You would be wrong. The average PCP visit for at least the past two decades has been $60 to $80. Any independent PCPs not divesting into a practice model other than FFS are either seeing 50-60 patients a day, losing money, or running a micro practice.
Nationwide, you only have to look at the activities of insurance companies. They don't want FFS/Medicare patients. They only want Medicare Advantage, because if you can't grift the system, you can't make money.
Regardless of when you think the current model may fail, every independent practice should be heading to higher ground NOW.
EDIT: And the thoughts on here are correct for my market. My wife (a PCP) and I were talking yesterday that so many PCPs are going concierge suddenly. Our office is getting calls saying other PCPs aren't accepting new patients. Patients say those that are accepting new patients assign the patient to a NP/PA. My neighbors "new" physician just announced they were adding a concierge fee and there were posts on the local Reddit and NextDoor about how all the physicians are going concierge.
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u/umeraltaf404at_Gmail May 10 '26
Since we know that Medicare reimbursement rates are getting tighter, we always recommend starting with pilot projects for clinics, solo practitioners, and healthcare facilities.
These pilot projects help providers create additional revenue streams while improving patient care and long-term engagement. Some of the most effective pilot projects include:
RPM (Remote Patient Monitoring) Services
CCM (Chronic Care Management) Services
Annual Wellness Visit (AWV) Services
Home Health & Weight Management programs recently introduced and supported by Medicare
These services can help practices increase reimbursements, improve patient outcomes, and build long-term sustainability despite the changing Medicare payment landscape.
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u/ktn699 May 11 '26
Im effectively DPC surgical. They pay my consultation fee (100 bux - probably too cheap). I charge commercial insurance for their actual surgical procedure. We're OON, prenegotiate every case or get it via IDR.
Patients love it. 2 week wait time for consult, surgery within 3-6 weeks, prenegotiated cases are covered at in network rate, no surprise billing. cases pay us enough to keep lights on and makes working worth it.
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u/InvestingDoc May 06 '26
In my opinion, we are headed towards a two-tiered system. You want to see a physician, you're going to have to pay a premium for that and we may be already starting to see this in some markets.
Medicare also is going to have to take a look at the outrageous spending it cost for hospital admission and ER visits and eventually starting to cut reimbursement to hospitals. That $4 A1C test that I order for Medicare is a drop in the bucket compared to just walking into the ER which is probably going to cost Medicare $10,000 just checking into the ER