HERE’S THE DIRTY SECRET ABOUT THE CASH VERsus insurance debate — you’re asking the wrong question. Walk into any chiropractic conference, and you’ll hear the same tribal warfare. The cash-practice evangelists preach freedom from insurance tyranny and overlords while turning away those who insist on the practice filing their insurance for them. The insurance-based docs defend “access to care” while secretly drowning in paperwork.
Both sides are convinced they’ve cracked the code. They’re both wrong.
According to Chiropractic Economics ’ annual surveys, the average DC sees mixed payment sources, but there’s something that those numbers don’t show. Reimbursement rates have plummeted from 69% in 2021 to 57% in 2024, while average fees have increased. Insurance-based practices are working harder for less money and forced to see more patients to fill the gap.
But the cash crowd isn’t winning either. Research across health care shows it costs five to 25 times more to acquire a new patient than to retain an existing one. When you go cash-only, you’re betting your entire business on constant new-patient acquisition in a market where 36% of patients left their healthcare provider in the past two years.
“Research across health care shows it costs five to 25 times more to acquire a new patient than to retain an existing one.”
So who wins? Neither.
The real problem isn’t whether you take insurance. It’s building a practice model where someone else — insurance companies or the fickle cash-pay market — controls your destiny.
Smart independent practices are doing something different. They’re diversifying revenue streams.
Healthcare revenue diversification studies show that practices with multiple income streams demonstrate greater financial resilience and can better weather economic downturns. Organizations that rely on single revenue sources face significantly higher financial vulnerability when that source changes.
The Chiropractic Economics 2024 survey showed group practices maintaining slightly better reimbursement rates (59%) than solo practitioners (55%), but it wasn’t the insurance versus cash decision driving that difference. It was operational efficiency and diversified service offerings.
Meanwhile, reimbursement disparities persist. When DCs and MDs bill the same CPT codes, the gap is stark.
For code 99203, MDs averaged $124 while DCs received $85. Medicare rates have declined while administrative costs climbed, squeezing practices that depend solely on insurance revenue.
The practitioners winning right now are those who stopped fighting the religious war and started thinking strategically. They accept insurance but aren’t dependent on it. They offer cash options but don’t rely solely on them. They’ve built recession-proof businesses, not battles.
Health Affairs research on organizational resilience confirms that revenue diversification isn’t just about adding sources; it’s about creating financial adaptability and sustainability. Practices with balanced revenue portfolios consistently report higher per capita revenues and better ability to withstand market disruptions.
The debate itself is the trap. While we’re arguing about payment models, we’re ignoring practice models.
Stop choosing sides. Start building antifragile practices that can weather whatever comes next, whether that’s more insurance restrictions, economic recession, or the next corporate chiropractic franchise opening down the street.
The question isn’t cash or insurance. It’s control or chaos.
Dr. Chris Tomshack, founder and CEO of Healthsource Chiropractic, leads America’s foremost network of premium disc and spine centers. Contact him at 440-934-5858 or ctomshack@hea lthsourcechiro.com. Learn more at TheChiroBlueprint.com.
1. Chiropractic Economics Annual Fees & Reimbursements Surveys, 2021-2024
2. Etactics, “Patient Retention and Chum Rate Statistics,” 2024
3. Health Affairs, "The Importance of Diversifying Funding Streams,” 2024
4. Chiropractic Future National Fee Schedule Equity Project, 2025
5. Multiple healthcare revenue diversification studies, 2024-2025
