Insurance Dependence or Clinical Independence?
Written by: James Demetrious, DC, DABCO
Board-Certified Chiropractic Orthopedist
Founder and CEO, PostGradDC
A $12 Lesson
When I entered chiropractic practice 40 years ago, an insurance intermediary denied payment for a $12 office visit because I had incorrectly completed a form. Twelve dollars was insignificant, but the lesson was not. I quickly learned that accepting third-party payment also meant accepting an expanding system of rules governing documentation, reimbursement, utilization, and, increasingly, how healthcare was delivered.
Early in my career, I made a decision that would shape the next four decades of my professional life.
I opted out of virtually every insurance panel except Medicare and practiced predominantly on a cash basis. It was not a rejection of accountability. In many respects, practicing independently demanded greater accountability.
When patients pay directly for their care, the doctor must continually demonstrate value. Every examination, treatment, imaging recommendation, referral, and follow-up visit should have a legitimate clinical purpose.
Care Based Upon Need, Not Reimbursement
My philosophy was simple. I did not believe in prescribing lengthy contracts of care simply because patients were willing to purchase them. I did not routinely provide multiple therapies simply because they could generate additional revenue. If something did not meaningfully contribute to the patient’s care or outcome, I saw little reason to provide it.
I tried to deliver the care that was necessary, avoid what was unnecessary, charge a fair fee, and treat every patient as I would want a member of my own family treated. Most importantly, clinical decisions remained between my patient and me.
When Administration Begins to Influence Care
Healthcare certainly requires accountability. Insurance serves an important purpose for patients facing significant medical expenses. The problem arises when financial and administrative systems begin to exert undue influence over clinical judgment.
Over the course of my career, I watched healthcare become increasingly burdened by prior authorizations, utilization reviews, coding requirements, reimbursement restrictions, audits, denials, and retrospective determinations of medical necessity. Collectively, however, they can create an environment in which doctors spend an extraordinary amount of time satisfying administrative requirements rather than examining, educating, reassuring, and caring for patients.
Even more concerning is the potential for reimbursement policy to alter clinical behavior. A doctor should not provide a treatment simply because an insurer will pay for it. Conversely, appropriate care should not be withheld simply because authorization is difficult or reimbursement is inadequate.
The patient’s clinical needs must remain the primary consideration.
Clinical Independence Must Be Earned
Clinical independence should never be confused with freedom from accountability. Autonomy requires competence, ethical behavior, appropriate documentation, informed consent, evidence-informed decision-making, reasonable utilization, recognition of one’s limitations, and referral when necessary.
The privilege of making independent clinical decisions carries with it the responsibility to make those decisions wisely. Whether a doctor participates in insurance networks, practices independently, or uses a hybrid model is ultimately an individual professional and business decision.
The more important question is not how the doctor is paid. It is who determines the care.
Protect the Doctor-Patient Relationship
After nearly 40 years in practice, I remain concerned whenever healthcare systems progressively move clinical decision-making away from the examination room and toward organizations and individuals who have never examined the patient. Doctors must certainly be accountable for the care they provide, but accountability should support sound clinical judgment rather than replace it.
My career taught me something remarkably simple: do what is necessary, avoid what is unnecessary, document why, charge fairly, measure your results, refer when appropriate, and never allow the financial interests of either the provider or the payer to become more important than the welfare of the patient.
I was fortunate to make a good living, support my family, enjoy a rewarding professional career, and eventually retire comfortably. But the greatest benefit of practicing independently was never financial. It was the ability to sit across from a patient, determine what I believed that person genuinely needed, discuss the options honestly, and make a decision together.
Be the Doctor
Take responsibility for your decisions. Put the patient first. And protect the doctor-patient relationship. It remains one of the most important relationships in healthcare.
PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is a distinguished board-certified chiropractic orthopedist, educator, author, and editor.
© 2026 – James Demetrious, DC, DABCO. Open Access. Unrestricted use, distribution, and reproduction are allowed in any medium, provided you give appropriate credit by citing the original author and source: Demetrious J. Insurance Dependence or Clinical Independence? PostGradDC.com; 2026.
