Submitted June 23, 2005
Suggested title:  Insurance-free medicine for retiring ER docs
Word count: 750

Four and a half years ago I left emergency medicine to start an insurance-free urgent care.  My original plan was to taper slowly from ER work to see whether a clinic not accepting insurance could be financially viable. While preparing for my gradual entry into uncharted waters, the hospital administrator had my contract terminated abruptly.  Rather than trying to find another ER position, I decided to make the plunge – for better or for worse – into a full-time, cash-only practice.

The impetus for this radical departure had been growing for several years as I came to know many of the patients living in our small rural town in northeast Tennessee.  Some were designated “self-pay” on the ER chart, and contrary to my initial assumptions about uninsured patients I came to realize that most were neither destitute nor derelict.  They were farmers, carpenters, mechanics, restaurant owners, beauticians and other hard working folk, many from whom I had received goods and services at fair and honest prices. 

Unfortunately, I could not say the same about what I charged them for non-emergency care such as laceration repairs or treating simple infections.  The bill they received for professional services might have come from PhyAmerica, but it was the full “rack rate” – far higher than our discounted fees to third party payers – and there was no escaping the fact that I was still the one responsible.  The idea of the clinic, therefore, took shape in the context of answering for myself the age-old questions, “Who is my neighbor?” and “How should I treat him?”  

I figured that by avoiding the costs associated with billing third party payers I could still make a decent living charging much less than what the local ER’s and urgent care do.  If Americans could pay at the time of service for oil changes and brake jobs, I reasoned that they could pay directly for primary medical care in the same price range.  Rather than concealing my fees as do hospitals, ER management firms, and other physicians, I publicized them in the local newspaper, on billboards, flyers, and on the sign in the front of our clinic – poison ivy $25, simple infections $35, simple lacerations $95. 

Even though many colleagues and other health care professionals have dismissed the clinic as just one man’s quixotic quest, other Americans are genuinely interested in ways to make healthcare more affordable.  In November 2003, The Wall Street Journal featured our clinic on the center of its front page.  I subsequently was asked to testify before Congress on the topic, “Consumer-Directed Doctoring.”  SimpleCare, a network of about 2000 cash clinics, has been the cover story for US News & World Report and has appeared on other national media. 

While the medical community here has not supported the clinic, other locals have.  With nearly 6000 patient charts, approximately one-tenth of the population of our county has visited the clinic since its inception.  Roughly 60% of those have been uninsured.  Thus far this year at an average of 3.7 patients per hour, my net hourly income has been higher than the current hourly rate at the ER where I last worked.  Our clinic has demonstrated the financial viability of practicing insurance-free medicine while providing timely, quality medical care to the uninsured.   

While ER medicine offers the professional satisfaction of caring for critically ill and injured patients, most of us can’t do it forever.  The wear and tear of night shifts eventually forces most of us to find other professional challenges and sources of income.  When contemplating retirement from ER work, emergency physicians would do well to consider the option of starting insurance-free medical clinics like ours.

They are simple to establish.  There are no Byzantine 50 page insurance contracts to scrutinize and sign, and no expensive computer systems and billing software to evaluate and purchase.  Since we don’t do any billing, we are exempt from having to comply with HIPAA regulations.  While other similar clinics usually have more than four employees, ours needs only one. 

Besides simplicity, insurance-free clinics offer just that – freedom.  We are free to set our own fees.  Free from arbitrary documentation requirements and other coercive and wasteful mandates from dehumanizing bureaucracies.  Free to refuse care to the disruptive and unappreciative who have come to believe they are entitled to our services. 

We are free, now, to reconnect with the pure, spiritual purpose for which we entered medicine – to attend to the medical care of people who in turn value and appreciate our knowledge and skill. 

Robert S. Berry, M.D. is board certified in emergency and internal medicine and practices at PATMOS EmergiClinic in Greeneville, TN.  He can be reached online at
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