CASH-ONLY dermatology practices offer physicians greater autonomy but raise ethical concerns about equitable access to care.
As direct patient contracting models expand across the United States, questions are emerging about their impact on healthcare disparities, patient affordability, and physicians’ responsibilities to underserved populations.
Direct patient contracting practices, including cash-only, concierge, boutique, and direct care models, allow patients to pay out of pocket instead of, or alongside, traditional insurance coverage.
Between 2018 and 2023, the number of direct primary care and concierge practice sites increased by 83.1%, reflecting growing interest in alternative healthcare delivery models.
Dermatology may be particularly suited to this transition because of its substantial volume of elective procedures and administrative challenges associated with insurance reimbursement and prior authorization requirements.
Cash-only dermatology offers potential advantages for physicians and patients. By reducing administrative burdens, these models may improve physician autonomy, professional satisfaction, and practice sustainability.
Physicians working in direct primary care models have reported lower burnout and greater professional fulfillment. Smaller patient panels may also enable longer consultations and more personalized care.
For patients, direct payment arrangements can provide clearer pricing and reduce complications associated with insurance denials, unexpected bills, and prior authorization delays.
Cash payments may even represent a less expensive option for some patients enrolled in high-deductible insurance plans.
Despite these benefits, concerns remain about whether cash-only dermatology could worsen existing inequalities in healthcare access.
One study cited in the ethics analysis found that appointment success rates were just 17% among Medicaid patients, compared with 96% among privately insured patients and 94% among Medicare beneficiaries. Medicaid patients also experienced longer waiting times.
Transitioning to cash-only care could further restrict access for patients unable to afford direct payments, potentially disrupting established physician–patient relationships.
Smaller patient panels may also shift greater demand toward insurance-based practices, increasing pressure on clinicians caring for financially disadvantaged populations.
The ethical challenge involves balancing physicians’ financial sustainability and professional well-being against their responsibility to provide accessible, equitable care.
Medical ethics guidance permits retainer-based practices while emphasizing physicians’ obligations to maintain quality care and avoid patient abandonment.
However, evidence specific to cash-only dermatology remains limited, with much of the available research originating from primary care.
Further research is needed to determine how these models affect dermatologic access and healthcare disparities.
Physicians considering alternative payment structures must weigh their professional autonomy against their obligations to the broader patient community.
Reference
Wu AX et al. Ethical Implications of Cash-Only Practices in Dermatology. J Am Acad Dermatol. 2026. doi:10.1016/j.jaad.2026.10.092.
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