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COD = Cash-Only Doctors

When Chuck O'Brien visits his doctor, they talk about his aches and pains, his heart problems and his diet, but never about his health insurance.

That's because his doctor only accepts cash.

Dr. Vern Cherewatenko is one of a small but growing number of physicians across the country who are dumping complicated insurance contracts in favor of simple cash payments.

When O'Brien leaves the exam room, he writes a check for $50 and he's done — no forms, no ID numbers, no copayments.

"This is traditional medicine. This is what America was like 30 years ago," said O'Brien, 55 and self-employed, who believes he has saved thousands of dollars by dropping his expensive insurance policy and paying cash. "It's a whole world of difference."

Is this the health care wave of the future? Probably not, experts say. Most people are content with monthly premiums and $10 copays; nine out of 10 doctors contract with managed-care companies.

For the 43 million Americans who lack health insurance, cash-only is a fact of life when a trip to the doctor or the pharmacy cannot be avoided.

Even when treating patients who are insured, some doctors - frustrated by red tape at the insurance companies - view cash-only medicine as an increasingly attractive way to run their businesses.

"It's a terrible indictment of the collapsing health care system," said Arthur Caplan, chairman of the medical ethics department at the University of Pennsylvania Medical School. "Insurance and managed care were supposed to streamline - instead what they've done is add so much paperwork and bureaucracy they're driving some doctors out."

Health insurers downplay the trend, while emphasizing recent efforts to mend tattered relationships between doctors and managed care companies.

"I don't look at it as a threat," said Mohit Ghose, spokesman for the industry group America's Health Insurance Plans. "It's just a different way of practicing."

Medical establishment leaders don't object to doctors working for simple cash.

"This is America. One size does not fit all," said Dr. John C. Nelson, president-elect of the American Medical Association. "We certainly support the physicians' right to do that."

An obstetrician-gynecologist in Salt Lake City, Nelson easily recalled times when he believed managed care rules prevented his patients from getting the best treatment. He said cash-only doctors are driven by the desire to practice medicine without interference.

"There is a great intrusion by third parties into the patient-physician relationship," Nelson said. "We can understand their frustration."

Cherewatenko, a broad-shouldered 45-year-old who wears black jackets and red stethoscopes at work, switched to cash out of desperation six years ago. His suburban Seattle practice was hemorrhaging money, and he and his partners realized they were spending hundreds of thousands of dollars just to process insurance paperwork.

"We said, 'Let's cut out this administrative waste,"' Cherewatenko said. Before, he charged $79 for an office visit and got $43 from an insurance company months later, minus the $20 in staff time it took to collect the payment. Now he charges $50 — and he never worries about collection costs, because patients pay in full after every visit.

Cherewatenko sees fewer patients now. His whole office would probably fit inside his old waiting room. But he says the freedom is worth it.

"Accounts receivable is zero. It's a great feeling," Cherewatenko said. "I feel like I'm a real doctor again."

He started a group called SimpleCare to spread the gospel of cash-only medicine. The organization steers patients to doctors who offer cash discounts, and gives technical and moral support to doctors who want to start cutting their ties to insurance. Membership has grown to 22,000 patient members and 1,500 doctors. Some reject all insurance and take only cash, while others continue to accept insurance while offering discounts of 15 percent to 50 percent for cash-paying patients.

Independent of SimpleCare, doctors in California, Colorado, Minnesota, Texas, Mississippi and other states have also quit the insurance game. Some tired of the paperwork and administrative expenses. Some wanted to spend more time with patients without managed care bean-counters peering over their shoulders. The patients who pay cash range from poor to wealthy, with most in the blue-collar middle.

"When I first started, I thought it would be the elite. That's not the case," said Dr. Shelley Giebel, an obstetrician-gynecologist in Temple, Texas, who washed her hands of insurance eight years ago.

Her standard, hour-long annual checkup costs $140. Everyone pays cash.

If a patient needs extra tests or treatment, Giebel tells them upfront what it will cost.

"If it is an urgent test, we'll go ahead and do it. We're not going to delay medical care because they don't have the money in hand," she said. Often, patients return later with the money.

"It has usually not been a problem that people forgo medical care," she said.

The cash-only movement isn't just changing the way people pay, it's changing the way these doctors work. Because of managed care's low reimbursement rates, doctors on insurance contracts must limit their time with each patient.

Giebel, a typical example, said she would have to double her patient load to make ends meet if she relied on insurance — something she can't imagine. "How can you possibly talk about prevention of cancer and heart disease when you're seeing patients every 12 minutes?" she asked.

Cash-only patients rave about the quality of care.

"They take time here with you," said Jesse Rainwater, a 59-year-old church pastor from Bellevue, Wash., who credits Cherewatenko with teaching him to manage his diabetes. "They don't just bring you in and run you out like a bunch of cattle. You feel like you're loved."

The cash-only approach evokes Norman Rockwell-tinged visions of country doctors being paid with chickens. The simplicity is tempting, but the truth is many people went without preventive health care in those "good old days." A $50 charge can be powerful incentive to delay seeing a doctor until you're in pain — which can lead to more expensive health problems later.

"Medicine used to be a cash-only business, and there were certainly many people who didn't have the cash," said Caplan, the medical ethicist. Doctors who insist on cash also have an ethical obligation to help people who can't afford the fee, he said — even if it means accepting chickens.

Cash crusaders acknowledge the need for some type of insurance. Without it, expensive surgery or hospitalization would force most people into bankruptcy. But they think health insurance should work more like car insurance: you pay for the routine maintenance and little dings yourself, and insurance pays for more expensive repairs.

O'Brien, a freelance marketing specialist, switched from a comprehensive health plan with $300 monthly premiums to a catastrophic plan that costs $75 a month, with a $2,000 deductible. He pays out-of-pocket for routine checkups, and his insurance will kick in if he ever needs expensive care.

The promise of a simple cash payment lured him to Cherewatenko's office, but the doctor's personal attention keeps him coming back. The $50 exams are just part of the bargain for O'Brien. Cherewatenko recently met him for coffee to talk about improving his diet — including an admonition to cut back on caffeine.

"How often does your doctor go out and have a cup of coffee with you?" O'Brien asked.

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