Ten years ago, College Park physician Rick Baxley made what seemed like a radical decision: He closed his large family practice, downsized his office and stopped accepting insurance.
Tired of working longer and harder to keep his practice profitable in the face of declining third-party reimbursements, Baxley began requiring that his patients pay him directly instead.
"The cost of service was going up, but reimbursement had leveled off. From a business perspective, it just didn't make sense," said Baxley. "From a personal standpoint, it was not fulfilling to see patients every 10 minutes. My style of practice is to sit down and talk to folks. It got to the point where I dreaded going to work, so I decided to shut down my practice and start from scratch."
Some called it a desperate move that would destroy his medical practice. Instead, Baxley's office is thriving.
Experts say the current economic climate has increased the patient base for cash-only medical practices. Many patients who have lost their jobs — along with their health insurance — are turning to these types of practices, which typically charge less for basic health services.
Among Floridians younger than 65, which is the age that Medicare kicks in, nearly one in four lacks health insurance, according to the U.S. Census Bureau. Florida is third among states with the highest percentage of uninsured residents.
Michael Miltonberger of Winter Park is one of them. The 55-year-old automotive mechanic who suffers from the autoimmune disease systemic lupus erythematosus, has gone without medical insurance for several years.
"I was kind of like, fired, by my last doctor because I didn't have insurance and I couldn't afford a $4,000 test or other procedures they would normally have for sick people," he said. "Dr. Baxley knows what I can afford and what I can't. He basically keeps me on my feet."
Even patients who are employed but have seen their insurance deductibles escalate are seeking cash-only practices.
"The majority of our patients belong to PPOs (preferred-provider organizations), but they have such high deductibles that many patients never meet the deductible," said Baxley.
For patients who have met their deductible, Baxley said his office will offer to send a bill to insurers for an additional $5, but that's about all the paperwork shuffling his staff will do. Patients must do their own paperwork and seek reimbursement for Baxley's bills. A typical office visit is $80.
At one time, Baxley, who ran his practice with two partners at RDV Sportsplex in Maitland, paid a team of four people to deal with managed-care companies. This only worsened his declining revenue.
Ed Haislmaier, a health-care researcher at the Heritage Foundation in Washington, D.C., said the frustration and expense dealing with insurance companies is partly what's driving the shift to cash-only.
"You're going to see more physicians saying, 'I'm not going to deal with them directly any longer,' and put the burden of that on the patient," he said. "It's not dissimilar to the way you deal with other types of third-party insurance, like auto insurance. Recently, my house was hit by a driver. The house needed a lot of repair work. We took bids, and hired a contractor… in a cash-only transaction, it doesn't mean you won't get reimbursed for services, you just have to pay up front for it."
Haislmaier said cash-only practices were best suited for primary-care physicians because costs for their services are significantly less than specialists for more complicated or severe illnesses. Baxley added cash-only does not work for hospital-based practices because they are often tied to hospital system billing systems.
The Mending Group in Baldwin Park is a cash-only counseling practice that opened in December 2009 to address the need for affordable mental-health services.
"With our unemployment rate as high as it is, there are many people without insurance who really need counseling. Financial problems are a leading cause of anxiety, depression, addictions. They take their toll on relationships," said John Super, who formed the practice with professors and students from the University of Central Florida. "We realized there were not a lot of counseling resources at a time when people needed counseling the most."
Services at The Mending Group are considerably less than normal rates, ranging from $75 to $100 for a 50-minute session with a PhD, mental-health counselor or marriage and family therapist, and $55 to $75 for a counseling or therapist intern.
Another option for patients with high deductibles or no insurance is the growing number of convenient care clinics with fixed menu pricing such as Take Care Clinics located at Walgreens drugstores, CVS Pharmacy MinuteClinics and Solantic walk-in urgent care clinics.
Marquita Fuchs, lead nurse practitioner for nine Take Care Clinics located inside Walgreens pharmacies in Orlando, said about 30 percent of local patients pay cash for services. Although she said she did not have data on how that figure has changed over time, Fuchs said she has noticed an increase in cash-paying patients as the economy has worsened.
"It depends on what part of town you're looking at, with some clinics having more cash-paying customers than others," said Fuchs. "But people do come in and share with us that they've lost their job and, therefore, their Insurance. Many people have also told us they come to us for low-cost health services because of a high deductible. In both cases, people recognize the importance of routine primary care."
Treatment for common illnesses starts at $65 for cash payers and/or the uninsured. Procedures, vaccines and physicals are priced separately. If insured by a plan that covers a visit to the clinic, patients pay their insurance co-pay.
While services at convenience care clinics like Walgreens' Take Care and CVS' MinuteClinics are provided by certified nurse practitioners who have access to medical doctors, Solantic clinics are staffed by physicians and provide a wider range of health services with a pricing structure broken down by basic, moderate and complex procedures. Prices range from $89 to $229 or less for physicals, immunizations and screenings.
Although these practices are addressing the needs of the uninsured and underinsured as well as patients with high insurance deductibles, for patients like Miltonberger, it's also about quality of care.
"Dr. Baxley is easy to get along with, and seems to have a genuine interest in my well-being," Miltonberger said. "If you have a doctor that you like, insurance or no insurance, he's worth going to."