The Cash-Based Dermatologist

Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health.

This week I sat down with Dr. Joni Sago, a remarkable physician, internist, and dermatologist, to discuss her journey into opening a cash-based dermatology practice and what that means for patient care. We talked through the evolving state of medicine, where corporate models and insurance structures dominate how doctors practice—often to the detriment of personalized care. Dr. Sago shared her personal story of frustration within the insurance-based model, highlighting how billing and electronic health records—designed more for corporate profits than patient outcomes—limited her ability to spend meaningful time with patients and provide quality care. She described how transitioning to a cash-only model has enabled her to spend more time focusing on patients’ real needs, offer comprehensive education, and actually improve their outcomes, especially for complex issues like skin cancer and chronic rashes.

One of the most refreshing aspects of Dr. Sago’s new approach is how it returns to the roots of patient-centered medicine. By stepping away from insurance-driven limitations, she now has the freedom to pursue real, root-cause medicine—looking into lifestyle, diet, stress, gut health, and other systemic issues that affect skin conditions. The result is not only quicker access to care (patients can often be seen within a day or two instead of waiting months), but also more thorough, actionable treatment plans and better communication.The system she’s developed even allows Medicare patients with supplements to be reimbursed, reducing out-of-pocket concerns for many seniors, and her streamlined process for referrals from primary care doctors makes it easier for those with urgent dermatological issues to get timely help.

PODCAST NOTES 

• The corporatization and insurance takeover in medicine has shifted the focus away from the patient, making it harder for doctors to actually care for their patients as individuals. Instead of being able to focus on a single patient’s needs, doctors are pressured to see more patients in less time, often just to navigate insurance requirements and billing codes. As Dr. Sago pointed out, even dermatology is getting swept up in this trend, and patients ultimately receive less personalized attention as a result.

• Insurance companies have implemented electronic health records and AI-driven systems that prioritize certain keywords over actual clinical judgment or patient outcomes. This results in denied or down-coded claims, forcing practices to ramp up their patient volume to stay financially viable. The consequence is that doctors lose the time and space to recall important patient details and actually connect with people, lowering the overall quality of care significantly.

• A cash-based practice model removes these insurance-imposed obstacles, allowing for longer, more meaningful appointments. Instead of rushing, Dr. Sago can provide head-to-toe skin exams and in-depth patient education, spending the time needed to ensure patients both understand the treatment and get the care they deserve. This is especially vital for patients with a history of serious conditions, such as melanoma, where attention to detail can be life-saving.

• Many patients may not notice a difference in the immediate logistics of their care, but what they don’t see—yet deeply benefit from—is that they are receiving a far more comprehensive, thoughtful examination and follow-up. From the doctor’s perspective, this means less paperwork and more face-to-face focus, which translates down the line into better diagnostic outcomes, fewer missed details, and higher satisfaction as patients actually get better.

• When primary care doctors lack dermatology training, patients with rashes or other skin issues often get funneled into urgent care or even emergency rooms, where nobody knows their history and true solutions are rarely offered. This system is costly, inefficient, and leaves patients paying far more (sometimes hundreds of dollars per visit even with insurance) than if they went directly to a cash-based dermatologist who could resolve the issue quickly and correctly.

• Dr. Sago’s new model offers streamlined access to care—by eliminating unnecessary referrals and restrictive waitlists, patients can book appointments online or get same-week visits. Primary care doctors can send referrals through secure messaging with just a patient’s name and number, avoiding paperwork delays. This is a huge shift from the typical dermatology experience, where waits of six months are common and urgent cases are often mishandled.

• For Medicare patients with traditional coverage and a supplement, her system supports claim submission for reimbursement—even though she’s out of network. Patients pay up front, and typically receive a check from Medicare and their supplement a few weeks later. This ensures senior patients, who are the most vulnerable to skin cancers and related diseases, don’t lose out on access to high-quality care simply because of insurance bureaucracy.

• Perhaps most importantly, true dermatologic care goes beyond simple prescriptions. Dr. Sago actively explores the root causes of symptoms, integrating questions about overall health, diet, sleep, stress, and gut function. She educates and empowers her patients, equipping them to manage their skin conditions in context with their whole-body health, which is rarely possible within rushed, insurance-driven visits.

The movement toward cash-only, patient-centered medicine, as exemplified by Dr. Sago’s new practice, is giving both physicians and patients what they need: time, attention, and real healing. It’s a return to personalized medicine, powered by the most advanced, up-to-date science but rooted in the kinds of doctor-patient relationships that truly improve health. If you’ve been frustrated by long wait times, rushed visits, or impersonal care, I urge you to consider exploring cash-based options for your dermatology and primary care needs. Don’t settle for the status quo—seek out care that puts you first, gives you answers, and helps you feel better, inside and out. 

Give Dr. Sago’s office a call or reach out to learn more about how a modern, patient-focused approach to dermatology could change your health for the better.

Stay educated. Stay healthy. 

Till next week.