As insurers struggle to keep pace with rapid advances in biologics, diagnostics and AI-enabled care navigation, more physicians may turn to cash-pay models, according to Joshua Siegel, MD.
Dr. Siegel, the director of orthopaedic sports medicine at Exeter, N.H.-based Access Sports Medicine and Orthopaedics, told Becker’s he expects more patients to seek cash-pay services that remain outside traditional coverage, particularly as “insurance companies lag behind the science and speed at which medicine advances.”
This trend can be seen with biologics in many fields, he said, and the growth of functional medicine reflects shifting patient expectations.
“People want to not only react to injuries or disease, but rather alter and prevent subclinical manifestations of future disease processes,” he said.
Dr. Siegel pointed to a growing market for advanced diagnostics, including functional health programs and tests like Galleri, that have expanded while insurers “sort out if and how to respond or pay.”
Additionally, information access is changing how patients navigate care.
“Information in this new world is critical,” he said. “AI such as DoxGPT and others allow patients to be their own advocates, and search for doctors who will provide what they want. The days of only providing a limited scope of services and not informing patients of their many choices are over.”
In his view, the dynamic is familiar. New services often start as cash-pay offerings, gain patient demand and clinical momentum, and are later evaluated for broader coverage. Over the last five to 10 years, and accelerating more recently, he said he has seen this trajectory with treatments such as Class IV laser therapy and extracorporeal pulse activation technology, a type of shockwave therapy.
“Insurances say, ‘Well, we’re not covering that,’” he said. “But patients have read about them — the data is very good, the research has been sound — and they create significant value for patients.”
That demand, he added, is also tied to the way people weigh time and convenience.
“In this world where time is a premium, people don’t necessarily always want to walk through the traditional treatment algorithm,” he said.
This is accelerating as the typical sequence of orthopedic care — physical therapy, follow-up visits and imaging before moving to additional interventions — is no longer in favor, he said.
He also argued that some legacy approaches aren’t keeping up with the market. Cortisone, for example, has been “going the way of the dinosaur,” as evidence has raised concerns about tissue effects. This has pushed patients toward alternatives seen as more efficient and better tolerated, such as platelet-rich plasma and other biologic-based options.
Still, Dr. Siegel said offering cash-pay services inside larger systems can be complicated. Many facilities and institutions won’t even allow their physicians to perform these because they lack a collection or billing pathway or are wary of the compliance and liability issues that can come with cash payment, especially when a service could otherwise be covered by insurance.
“Certainly providing a service for cash payment that an insurance company would have covered, in and of itself, has tremendous liability, especially with Medicare,” he said. “Forms have to be signed, and legal methods and papers have to be adopted and adapted by the practice to allow these services to move forward.”
That can leave employed physicians in hospital-based or corporate settings with little ability to raise these services with patients, he added.
“For a lot of these employed doctors at larger institutions, there’s no huge incentive for them to discuss with patients that these services are available,” he said. “And secondly, even if they could, they might not have a method to provide for them. It’s hard to suggest something to a patient that you yourself can’t really find them access to.”
Independent physicians and ASCs may be better positioned to lead the next wave of cash-pay innovation, just as they have in other outpatient shifts.
“ASCs, outpatient MRI, or outpatient physical therapy — they were all pretty much started by independent physicians,” he said. “And then what happens is, once the model is proven or insurance finally jumps on, larger institutions incorporate it — start building out their own, trying to make it better, nicer, more convenient.”
That cycle is why independence often drives early adoption.
“I think most innovations that occur in medical fields occur at the hands of independent physicians,” he said, “who can not only provide those services, but can also provide them at such a cost-benefit ratio that they take hold in communities and eventually regions.
