How Access Healthcare Thrived as a Cash-Only Practice

What do you think of if I ask you to picture a doctor? A surgeon who cuts and sews? A doctor in the hospital doing rounds? A primary care doctor who only spends 5 minutes with you?

For me, when I picture a doctor, I think of an elderly, genteel man taking time to treat the patient and to relieve the patient’s fears. This doctor would be very much like how Norman Rockwell depicted a doctor in the painting titled Doctor and Doll. A doctor is patient, kind, trustworthy, and available.

access healthcare - doctor and doll

Norman Rockwell’s painting, Doctor and Doll, very accurately portrays, in my mind, what a doctor should be like.

Although I may not be elderly (yet) nor genteel (yet), I do hope to spend time with the patients to earn their trust and ultimately to practice good primary care medicine. Five to ten minutes per patient may not be enough to practice good medicine.

Through my interview regarding AtlasMD, I have learned it is possible to practice primary care like the “good old” days, a time way before my birth, through a concierge medicine business model.

I was fortunate enough to stumble across another business model: a concierge-lite or cash-only, direct-pay practice. I came across numerous articles about Dr. Brian Forrest, MD and his medical practice, Access Healthcare.

And true to its name, Access Healthcare tries to provide access to healthcare to all people, especially those that fall into the cracks of the US medical healthcare system. The people who fall into the cracks could be your neighbors, your peers, or your friends. They make just enough not to qualify for Medicaid but do not make enough to afford health insurance.

Without further ado, let’s find out more about Access Healthcare and hear what Dr. Forrest has to say in his video.

Access Healthcare in the News

Introducing Dr. Brian Forrest and Access Healthcare

Besides the video above, Dr. Forrest has generously shared information about Access Healthcare throughout the years. The earliest articles date back to 2002, when he first opened the practice, and the latest articles were written as current as 2011. These articles are so rich in information that if I wanted to, I could probably copy and set up my own practice today, if I was a doctor.

I will share with you what I have learned.

Access Healthcare’s Humble Beginnings

Dr. Brian Forrest started Access Healthcare on April 2002 in Apex, North Carolina. As I mentioned earlier, Access Healthcare is a cash-only, direct-pay or concierge-lite medical practice. No insurance is accepted (although a patient may file her own paperwork if she has health insurance to get reimbursed).

Dr. Forrest started this practice under the cash-only, direct-pay model for two reasons:

  • he did not want to deal with the bureaucratic hassles when trying to collect money from health insurance companies
  • he could not practice good medicine or even get to know his patients well if he worked for someone else or started a traditional insurance-accepting practice

The beginnings of Access Healthcare were humble. He started with one employee to help with the administrative tasks and to greet patients when they entered.

When he first started out, he had a humble goal: if he could pay his mortgage and take care of his patients, he would be happy. And he certainly took care of his patients. In one instance, when his patient was sent to the hospital for a heart attack, he put her groceries into the refrigerator so they would not spoil.

Just three years after starting his practice, Dr. Forrest had to close the practice to new patients. Before he closed his practice to new patients, he was getting an average of 15 new patients every week, without him doing any advertising. He had to hire additional employees to take on the new patients.

As of 2010, he gets 8 to 10 new requests for appointments every day. Again, this is with zero advertising.

Now, as of 2012, the staff grew from 2 to 5. If you want to be a patient there, it may not be easy. According to the practice’s website, “New patients are taken on a limited basis and it may take several weeks for new patients to become established with their first visit.”

What Do Patients See in Access Healthcare?

By looking at the growth in number of staff and the limited ability to take on new patients, it is very safe to say that Access Healthcare is wildly successful in meeting the patients’ needs. How does it do so?

Access Healthcare offers four things:

  • lower waiting time and increased time with the doctor
  • patients can be heard
  • good preventative medicine
  • lower costs

Less Wait, More Doctor

In traditional medical practices, you can expect to wait 50 minutes to only see the doctor for 5 minutes. But in this practice, it is different. “Patients get five minutes of wait and 50 minutes with me,” Forrest says. “In most offices, they get 50 minutes of gobbledygook and five minutes with the doctor.”

Some patients will need an hour; some patients will need only 10 minutes. On average, Dr. Forrest spends about 30 minutes with each patient. That is about 3 or 4 times longer than a consultation from a traditional practice.

How is the wait so short? Dr. Forrest see, at most, 16 patients a day, but only 8 of them are scheduled. He leaves the other 8 slots free. So that way, if a patient has an urgent medical need, she can stop in and get it checked.

Patients Have a Voice

Access Healthcare uses patient satisfaction surveys. Even though the feedback is largely positive (5 out of 5), Dr. Forrest is willing and wants to hear about suggestions and inputs from patients.

Good Preventative Care

The medical care provided through Access Healthcare is better than the norm. This most probably is due to the increased time Dr. Forrest has with his patients. Not only does he want his patients satisfied, he constantly monitors the outcome of his care in terms of blood pressure, hemoglobin A1c (test to see how well diabetes is under control), and cholesterol. His data shows that more of his patients are controlled for high blood pressure, diabetes, and dyslipidemia (high cholesterol levels) than the national average.

For example, one year ago (2nd quarter of 2011), the national average for patients with a controlled blood pressure is 50%. For Dr. Forrest’s patients, 85% with high blood pressure are controlled. Access Healthcare is in the top 10th percentile for getting the aforementioned diseases under control.

Lower Cost

Most importantly, the Access Healthcare provides medical care at a cost which is 85% lower. The US is currently in a recession and people are concern about costs. Obviously, they want value. And this practice can provide it in spades.

The prices are so good that people who do not have health insurance can afford medical care. To me, this is the single biggest appeal of the cash only medical practice model.

Surprisingly, only half of Forrest’s patients are uninsured. The other half are have private health insurance or Medicare. The reason that insured patients choose Forrest is that the medical fee is sometimes less than the co-pay to a traditional practice. Other people like the longer face-time with the doctor.

As of 2011, a metabolic panel (a blood test that provides lots of important data such as your blood sugar and electrolytes levels) would normally cost $169. Dr. Forrest provides it for $29. Cryosurgery to remove warts would normally cost $329. He provides it for $49.

He also works closely with specialists and lab companies so his patients could get discounts (of up to 85%) if they pay cash for services referred to outside the practice.

Why Are Prices at Access Healthcare Lower?

Now that you have an idea about Access Healthcare, I want to dig into the details of how it works.

Just as a side note, I will mention some accounting words and some numbers, but stay with me. I will make it as easy as possible for you to understand what they mean.

The best way to describe Dr. Forrest’s practice is a lean, mean, medical machine. He ruthlessly cuts costs. Why spend more money if spending less will do? The cost to operate Access Healthcare is much lower than the cost to operate traditional practices. If fact, it only takes 4 patients a day to break even, meaning it only takes 4 patients a day for Forrest not to lose any money. Since he usually sees 16 patients a day, it is no doubt that the business is profitable. His business was profitable within the first year.

“You don’t need to charge more to make more,” Forrest says. “You need to cut waste to make more.” That one sentence describes exactly how Access Healthcare is both so successful and profitable.

How does he cut waste? He reduces overhead (expense to run a business) by

  • buying used medical equipment and furniture
  • embracing technology
  • not accepting insurance

Buying Used Equipment and Furniture

In the American Academy of Family Physicians (AAFP) journal, Dr. Forrest went into great details of how he keeps overhead as small as possible. One of the things he did was buy medical equipment and furniture in hospital surplus stores. That would be similar to you buying your house furniture from Goodwill. Chairs were $2, compared to $199 if it was bought from a medical supplier. Exam tables were $100, down from $1,500. He also employed the same cost-cutting strategy when buying medical supplies.

Embracing Technology

Technology is wonderful. It simplifies life and makes you more productive. For example, a computer could be used to do work, connect with friends, watch shows, and more. Dr. Forrest used technology to lower costs and to increase efficiency.

One of the ways he did so was to implement a four-line phone system that uses wireless internet. Therefore, the traditional land-lines were not needed. The phone system was advanced enough that an operator or an answering service was not needed. This resulted in savings of several thousand dollars.

Dr. Forrest also set up his office to be totally paperless, similar to my study methods. Because all the information is stored in the computer, Access Healthcare does not need to spend so much for cabinets and paper filing systems. Having everything electronically saves time when retrieving information. In addition, when information is all there in once place, instead of on pieces of paper here and there, doctors are better able to practice good medicine.

Not Accepting Insurance

Even though the aforementioned points above are important, by far, the most important aspect to lower overhead is to not accept insurance.

“The major thing that’s made this work is keeping the overhead very low,” Forrest says. “In my opinion, what’s gone wrong with medicine is, we’ve assumed the burden of overhead that the insurance companies should have themselves. It’s a bureaucracy and administrative costs that they have caused, yet they are on our payroll.”

Dr. Forrest estimates that by not accepting insurance, Access Healthcare saves about $250,000 per year. His overhead is 25 percent of total revenue. In traditional practices, the overhead is between 40 percent to 60 percent of total revenue.

“The discovery I made was that by getting rid of administrative, bureaucratic hassles, I was able to do very well financially and at the same time have high patient satisfaction and good quality of care,” he says.

He saves by not having to hire extra staff to deal with the insurance companies. In traditional practices, you will need four staff per doctor. In this case, he started with only one staff. Currently, as of 2012, his staff to doctor ratio is still 1:1.

Less time is spent with administrative work. More time is spent with patients. He does not even have to buy a billing software, since he does not deal with insurance. And yet, his collection rate is 99.8 percent. He asks his patients to pay on the spot. By having a high collection rate, little to no money is spent collecting the money owed to him. This further enables Dr. Forrest to offer substantial savings for the patients.

Unlike most traditional practices, prices are clearly listed. “It’s a like a Jiffy Lube,” Forrest says proudly. “Patients can stand out here and add up their bill before they get seen. What other doctor’s office do you go to and all the prices are listed out front?”

Everyone Wins

With Access Healthcare, everyone wins. The patients get affordable health care, with or without health insurance. Dr. Forrest also makes a nice salary. Medical Economics estimated his 2010 pre-tax income to be between $270,000 and $495,000 a year.

I estimate his 2010 salary to be around $230,000. Access Healthcare has 2,500 patients in 2010. If half of the 2,500 patients see him again, that means he has 3,750 patient visits for that year. He claims a profit of $62 per visit. That results in a total profit of $232,500. He works about 40 hours a week. Assuming that he takes 2 weeks off per year, that results in 2000 hours worked per year. That means he makes over $100 per hour, which is really good compared for a family medicine doctor!

In 2012, he has another doctor and nurse to help take care of his patients. If he can still earn a profit even when someone else is taking care of his patients, he could make even more money.

However you calculate his income, it is definitely not bad, especially for a family medicine doctor.

Interview with Dr. Brian Forrest, MD

1. Please tell us a little bit about your background. Why did you choose to specialize in family medicine?

This could be a multipage answer but I will keep it brief. I like a lot of different things, and one of them is medicine. Ever since I was 16, I have wanted to be doctor. Why a family doctor? Well, when you ask people who their doctor is, they would give the name of their family doctor. When someone asks who your doctor is, nobody ever gives the name of their nephrologist, or at least not usually. My second choice would have been an ER (emergency room) doctor because that specialty comes with lots of variety. My third choice would have been in dermatology, which I get to do a lot of even as a family doctor. For my fourth choice, I would have chosen to be an ENT (ear, nose throat) doctor. I do a lot of that in my practice as well. So basically in family medicine, you can get to do 90% of everything and be people’s go-to source for healthcare.

2. Before you started Access Healthcare, did you have a business background? Could a doctor do what you have done without a business background? If so, how can he or she best compensate for the deficiency in business knowledge?

No, I did not start with a business background. But as you can see, a doctor can start this practice without previous exposure to business. But it would be helpful to have someone like myself as a consultant to get you started. I have helped hundreds of physicians start a practice like mine.

3. In the various articles about Access Healthcare (such as on KevinMD, Modern Medicine, AAFP), you cited many numbers, such as the profit margins of traditional practices for primary care and specialized care, expenses associated with collecting payments from insurance companies, etc. How did you come across these information? Are office mangers so open with the financials of the practices they run? Let’s say I want to open my own practice in rural Texas. How could I find out information that pertains to that location?

Medical Group Management Association (MGMA) has survey statistics with a lot of this information on a national and regional level. I have collected the individual practice information from practice managers at several different groups in the Winston-Salem Area of North Carolina. The practice managers were remarkably open because they saw working with Access Healthcare as a way to learn how they could be more efficient. If you want to know about a specific area in Texas, you would have to plug in some certain demographics into a formula I have created (with a total of 17 variables to input) that would give you a good idea of what it would look like there.

4. Why did you decide to add the annual fee (Access Card) payment plan? Was there a demand for it? Was it a way to get patients to agree to routine screening?

This is a long question and could take about 30 minutes to answer thoroughly so let me give you a simplified explanation. Think about how a gym makes money. They charge a membership fee based on knowing what their average overhead should be and on what profit they want to make. Now, imagine if they had to charge for every piece of equipment you used and every dumbbell you lifted, they would have to keep up with the charges for all of those individual fees. That would cost the gym more in overhead than just doing a monthly fee based on the law of averages. So that’s generally why I implemented the Access Card. In addition, it does encourage people to get their annual screening done because they feel like that does not cost them extra to do so.

5. How do you determine how much to increase prices each year?

This is based on our actual cost to deliver services and based on market forces, like what people’s normal out-of-pocket cost are and what their co-pays might be at an insurance office. In other words, we make sure we are profitable but also competitive. I sit down with a legal pad every year and run various scenarios while I am off for the Christmas holidays to figure out if I should raise prices and by how much.

6. How do you determine what services you will provide or not provide?

I offer services based on what I like to do. I like dermatology and preventive cardiology so I do a lot of that. Other providers in our practice do the same. For example, Dr. Mullens likes women’s health and gynecology, so she does a lot of that.

7. By running such a lean practice, are you able to take a 2-week vacation? If so, what happens to the patients when you are not there?

I can take a 2-week vacation. In fact, I have 6 weeks off per year. When I have on vacation, another physician and an FNP (family nurse practitioner) will cover form me.

8. It seems like your practice has reached it maximum capacity because new patients may have to wait a bit before getting their first visit. Is that true? How do you plan to expand?

I am expanding by adding new providers. I will likely hire 2 more full-time doctor or nurses this year. Another way for me to expand is by helping other doctors open offices like mine all over the country.

9. How is Access Healthcare able to have such a high percentile of patients reach hemoglobin A1C, LDL, and JNC goals compared to the national average?

We are able to take more than twice as much time with our patients that traditional medical practices, which allows more careful consideration of the treatment plan, more patient education, and identification and removal of barriers to compliance. As an example of removing barriers of compliance, we personally fill out, stamp, and mail patient assistance forms to make sure patients can afford their medications.

10. If you had to start the practice all over again, what would you do differently? What would you do the same?

I think I would do it exactly the same, Access Healthcare could not have turned out any better. We spend at least 30 minutes with every patient, receive double normal income per patient, do not have to deal with insurance hassles, and offer better access to healthcare for low income patients. It could not have turned out any better!

11. In 10 years, what will Access Healthcare look like? Will it be bigger? Will there be multiple offices? Will you offer more services?

I think it will operate much the same way with the exception that there will be literally 1000s of offices operating like us all over the country.

12. What would you advise for someone who wants to follow in your footsteps and open a cash-based, no insurance practice?

Read a lot. Some good resources are Medical Economics, Physicians Practice, and Family Practice Management. Then make sure to work with a mentor / consultant that has done it from scratch. There are at least 100 details of making this work that are not published.

Concluding Thoughts on Access Healthcare

Overall, this business model makes a lot of sense. Reduce expenses and charge a lower price. This is exactly how lots of successful companies operate: Walmart, Costco, Dell, etc. Why not apply it to a medical setting?

In a time when health care costs are steep and opaque, the low cost and clear prices that Access Healthcare brings are a welcome breath of fresh air.

Although there are many similarities between the cash-only, direct-pay model and the concierge model, the cash-only, direct-pay model allows me to service a few thousand patients instead of a few hundred.

This is another possible model for my future medical practice.

If you want to find out more about Access Healthcare, you can visit its website at


1. Access Healthcare

2. Untitled Article [June 2002]

3. 2,500 Cash-Paying Patients and Growing – American Academy of Family Physicians [February 2006]

4. NC Doctors Offer New Services – Heartlander [November 2006]

5. Breaking Even on Four Visits Per Day – American Academy of Family Physicians [June 2007]

6. How to Run a Cash-Only Practice and Thrive – Medical Economics [January 2010]

7. Cash for Doctors – The Weekly Standard [May 2010]

8. A Primary Care Direct Pay Model That Works – [August 2010]

9. How Direct Primary Care Reduces Primary Care Costs – [July 2011]

Attention! Do you want to make more money as a doctor? Do you want more freedom? Are you sick of all the useless, time-wasting paperwork? Do you wanna learn how to set up and run a profitable practice that only takes cash, from someone who has “been there and done that?” If yes, check out My Cash-Based Practice: Essential Knowledge for Creating a Successful Private-Pay Physical Therapy Practice — the best book I have found on starting and running a cash practice.

At the very least, check out the book review.

This article is part of the Money in Medicine series. Click on the link if you want all the money-making secrets available to doctors.

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