Cash-only practice, with John C. Cianca, M.D., FAAPMR, president of the American Academy of Physical Medicine and Rehabilitation

The consolidation of outpatient medicine has swept many independent physicians into larger systems, private equity arrangements or hospital employment. John C. Cianca, M.D., FAAPMR, a physiatrist in Houston and president of the American Academy of Physical Medicine and Rehabilitation (AAPMR), chose a different path.

More than two decades ago, he left his Baylor-affiliated medical college to build a true solo, cash-only practice. His office has no front desk, no medical assistants, no prior authorizations and no step therapy requirements.

Medical Economics Senior Editor Richard Payerchin talks with Cianca about why he made that move, what it cost him early on and what it freed him to do for patients. They also cover what primary care physicians consistently misunderstand about physical medicine and rehabilitation, how AAPMR became an early leader in documenting and advocating for long COVID patients, and how AI is already reshaping medical education in ways that may make traditional professional society programming obsolete.

Don’t miss our recent episodes on practice budgets, social drivers of health, compensation and contracts and physician-owned hospitals.

Music Credits:

CALM CHILL RELAXED SMOOTH JAZZ (OWE YOU) by Tasty Tunes - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:26 | Sponsor message Copic medical liability insurance.

0:26 – 0:58 | Cold open Dr. Cianca on the consolidation churn pulling outpatient practices into larger, less autonomous systems — and why he went the other direction.

0:58 – 1:55 | Introduction Austin Littrell introduces the episode, the guest and the key topics.

1:55 – 2:43 | Meet Dr. John Cianca Dr. Cianca introduces himself: private practitioner in Houston, adjunct faculty at Baylor College of Medicine and UT Medical Sciences, and president of AAPMR. His practice is a solo, cash-only outpatient musculoskeletal clinic.

2:43 – 4:43 | The biggest challenge facing PM&R Physical medicine and rehabilitation (PM&R) is a broad specialty spanning acute catastrophic injuries to day-to-day musculoskeletal care. The persistent external challenge: Rehabilitation is still treated as an afterthought in care delivery, when earlier involvement produces faster, more efficient outcomes.

4:43 – 9:10 | PM&R's place in the primary care landscape Many early misconceptions about physiatry have cleared, but it's still not the first call for nonoperative musculoskeletal problems — orthopedics tends to get the referral. Dr. Cianca makes the case for physiatry as a long-arc specialty rather than an incident response, and traces the field's evolution from hospital-based rehabilitation to outpatient care.

9:10 – 12:34 | AAPMR and long COVID Drawing on the specialty's history of managing post-polio rehabilitation, AAPMR recognized early that post-COVID conditions would require sustained attention. Dr. Cianca says access to long COVID care has become harder over time, not easier, as the health care system's urgency has faded and the broader public has moved on.

12:34 – 15:11 | The pressures on independent practice Administrative burden, consolidation and private equity have pushed many small practices into larger systems. Dr. Cianca describes the churn that has reshaped outpatient medicine and explains why he deliberately went the other direction — and why he was fortunate to start when he did.

15:11 – 19:03 | Why Dr. Cianca went cash-only Twenty-two years ago, Dr. Cianca left his medical college affiliation to build a solo, insurance-free practice. His motivation wasn't money — he says he earns less than most colleagues — it was time: time to speak with patients, teach them and change their course rather than treat volume. He acknowledges the financial difficulty of the early years and cautions that the model is genuinely hard to build.

19:03 – 23:10 | The practical reality of a cash-only solo practice No front desk, no medical assistants, no physician assistants — and no chasing approvals or unpaid claims. Dr. Cianca explains what it means to deliver care without having to justify clinical decisions to someone who may not fully understand what they're approving. On step therapy: It's not a savings, it's just a delay.

23:10 – 24:01 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

24:01 – 26:25 | Remote therapeutic monitoring and technology in PM&R Dr. Cianca describes how the specialty has long used implantable technology for spasticity and pain management and explains how PM&R's practically oriented culture has made it an early and consistent adopter of new tools — including outpatient microsurgical techniques that send patients home the same day.

26:25 – 29:24 | AI and the future of PM&R AI may be the biggest change Dr. Cianca has seen in his career, and it's already reshaping medical education. Residents are turning to AI for literature synthesis instead of reading primary articles, and professional societies are trying to figure out how to stay relevant without being made obsolete.

29:24 – 32:04 | PM&R and the "Make America Healthy Again" initiative Dr. Cianca's view: physiatry has been doing this work all along. The specialty's whole-person, function-first approach to care predates the policy framing. A colleague recently put it simply: "You've already been doing this anyway."

32:04 – 34:16 | A message to primary care physicians and outro Primary care is physiatry's gateway, and Dr. Cianca's message to primary care providers: for nonoperative musculoskeletal problems, physiatrists offer something orthopedics doesn't — long-term partnership across a spectrum of time, not just an incident response. Payerchin wraps the interview; Littrell closes the episode.