A quiet healthcare revolution is underway in several localities, as shown by the Tri-Cities medical community in Tennessee, where more local physicians have abandoned traditional insurance-based billing in favor of direct pay models, The Times News reports.
The shift, driven by mounting administrative burdens, shrinking reimbursements, and deep moral frustration, is reshaping how patients access care and how doctors practice medicine.
OB-GYN Dr. Ginger Carter is among the latest to make the leap. Carter recently transitioned her Johnson City practice to a direct pay system, a decision fueled by years of grappling with insurance company practices—most notably, the controversial process of “downcoding.”
This tactic, recently adopted by Blue Cross Blue Shield of Tennessee and soon to be implemented by Cigna Healthcare, reduces payments to providers by reclassifying submitted claims at lower reimbursement rates.
Carter’s office is a testament to the administrative toll: a thick folder labeled “APPEALS” sits on her desk, overflowing with paperwork from downcoded claims.
“Basically, I have to submit the claim at least two times, because the first time they’re going to downcode it,” Carter explained to the outlet.
Managing billing and insurance already requires three employees, and pursuing every claim would mean hiring yet another. “It’s just not sustainable,” she said.
The move to direct pay, also known as direct primary care, allows patients to pay their physicians directly, freeing providers from the labyrinth of insurance rules and reimbursement schedules.
Carter is not alone in this transition. Cardiologist Dr. Daniel O’Roark of Trinity Heart and Vascular Group adopted the model three years ago, motivated by both philosophical ideals and harsh fiscal realities.
“The reimbursements are getting less, and of course with all the inflation we’ve had over the last five years, practice costs are going up,” O’Roark noted.
For Joe Reid II, a certified physician assistant at Genesis Healthcare Center, the decision was also deeply moral. “The morality of it is a huge part of why so many people in medicine are just frustrated,” Reid said. “I was sick and tired of the insurance company being in the room with me.”
Patients, too, are noticing the difference. O’Roark reports that his patients now enjoy greater affordability, improved access, and more time with their provider. Carter has found her patients receptive, with most scheduling follow-ups under the new system.
With an estimated 2,400 practices nationwide now using direct pay—double the number from just three years ago—the trend shows no sign of slowing.
Local practitioners believe the model will continue to grow, especially as small businesses seek affordable healthcare solutions for employees. As O’Roark put it, “Now I feel like I’m practicing the best medicine of my career”.