The state of physical medicine: The beginnings of a cash-only practice

John C. Cianca, M.D., FAAPMR, president of the American Academy of Physical Medicine and Rehabilitation, transitioned to a cash-based, largely insurance-free practice 22 years ago not to increase his income but because he felt strongly that spending meaningful time with patients to teach, counsel and genuinely change their health trajectory was the only way he could practice medicine effectively. He cautions that the cash-pay model is financially demanding and difficult to build, even for an established physician with years of community recognition. Its success requires accepting lower income in exchange for greater clinical autonomy at a time when broader health care pressures are pushing most practices toward higher volumes and less time with patients.

Medical Economics: Could you talk more about your own experience and what influenced you to work in a cash only practice?

John C. Cianca, M.D., FAAPMR: Well, it is an interesting question, because I, as I said earlier, it started doing it 22 years ago, when there was people doing it, but it wasn't so unusual in the sense of what we have now, which is these vast systems. I did it primarily to allow myself to see people the way I thought was best for me and for them. I recognized early that I don't like or excel and treating fast and in volume. I much prefer to see people at a pace that allows me to spend time with them, speak to them, teach them and affect them, not just do something to them, but to change their course. That requires time. I don't know how else to do it. And therefore I sort of chafed at was what was being presented to me, which was, well, you got to see more patients to make your salary. And I was so ardent about what I wanted to do, I even suggested, well, why don't you just change my salary so we don't have that pressure. And that got resistance, believe it or not, and I kind of understand that, there's sort of a given template for how a hospital or a medical college needs to pay their employees, and that just didn't fit. So at that point, I left the medical college that I was associated with Baylor, amicably and started alongside of them, meaning as an adjunct, doing my own thing without insurance —without private insurance, I still took Medicare for many years after that. And that allowed me then to reduce volume and not reduce income. What I'll be careful to say is, I didn't get involved in that to make more money. In fact, I make less money than most of my colleagues who are treating volume and trying to keep up with the financial pace that they had before. That wasn't central for me. It was about providing care, and the monetary means or monetary rewards were secondary. So over the years, I've gotten more efficient and things work better. But it was a struggle early on. Despite feeling better about the care I was delivering, financially it was difficult. That's a hurdle you have to deal with if you're going to go the way I've gone. You can't just expect that your office is going to be full. I had 11 years in this area, so people did know me, and it was still hard. So it's a challenging way to go. I was fortunate to get in early before people really were feeling the pressure of new styles of practice, which is higher volumes, less time with people, more administrative demands and difficulties.