The Bigger Picture: The New Breed of Cash-Only Docs

May 1, 2006

It used to be that physicians who charged subscription fees were ostracized by their peers. That's changing. Doctors like Lance Carroll is one of the reasons.


There’s a sea change underway in the kind of physicians who practice cash-only. Lance Carroll, MD, personifies it.

It used to be that cash-only physicians were like the mean high-school jocks who partied a lot and got all the girls. At least, that’s how everyone else in the medical community saw them.

Traditional doctors both envied and hated them. How selfish. How preening. It might be lucrative to abandon your Medicare patients, goes the argument, but it’s hardly the right thing to do. And really, doesn’t the nice geek with the high-waisted pants and the mountain of EOBs in his office always win in the end? Better exhausted than cruel, right? Better friendly and poor than mean and rich. Right?

Fair or not, concierge physicians are the playboys everyone in their communities love to hate - and envy.

Meet Lance Carroll, MD. Yes, he’s young, handsome, and charming. But mean? Nope. Carroll is the new face of cash-only practices. Think friendly Prince Charming instead of brash bad boy.

When Carroll decided to transition his traditional primary-care practice in Austin, Texas, to a cash-only model, his friends and peers couldn’t believe it. “There was huge negative feedback from everyone because they thought I was just going to see rich people and was selling out. People wouldn’t listen any further. … Everyone just kind of looked at me with a half-cocked eye and was staring at me to see how it was going to work. One of the big things was actually jealousy. It’s kind of funny that anyone would be jealous of me.”

But Carroll is no libertarian or get-rich-quick schemer. He just wanted a model where he could work with patients he appreciates and who appreciate him. He calls cash-only care a “gentler approach.”

No extravagant, Trump-like fees here; Carroll works more like Robin Hood. He charges patients a monthly fee based on what their needs are - starting at just $35 a month. “Yesterday, I went out to the woods and saw people who have nothing. They are on a $60-a-month plan, and that lets me go to see them.” Carroll says he “tithes” 10 percent of his care time back to the community. That means he still sees Medicare and Medicaid patients; he just sees them for free.

To keep costs low, he communicates with patients almost exclusively via cell phone and e-mail and retains only one part-time manager. Check out his Web site at www.austinmed.net.

Carroll says he struggled with the ethics of seeming to abandon his relationships with patients who have Medicare and supplementary coverage - most of whom opted not to stay with his practice and pay for something they were used to getting for free. But he ultimately realized these patients had to do what was best for them.

He’s now working on a book about his experience that includes mental exercises for physicians to help them identify their values and work on their relationships with their spouses as part of starting up a concierge care practice.

Carroll has a Buddha-like aura. I met him at a two-day CME event, and every time I saw him, he was surrounded by a cluster of other young men and women who leaned in close as he told them about his ethical position. It was like watching a popular and intense yoga instructor after class. Or a handsome acoustic guitar player at a college party.

Carroll and the new breed of cash-only physicians are less like the bullying jocks from Revenge of the Nerds and more like that guy Molly Ringwald dreamed of in Sixteen Candles. Rich - but sensitive. The kind who has a blonde, beautiful, and popular girlfriend, but falls for the pouty-lipped redhead. He even remembers her birthday. He does the right thing and has it all together. Sigh…

Do you think concierge care can be kind? Tell me about it. Write to me at pmoore@physicianspractice.com.

This article originally appeared in the May 2006 issue of Physicians Practice.