Morning everyone! 

Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. To set the stage for this Note, I love talking with like minded providers about the cash only model for medicine! 

This past week I enjoyed having Dr. Daniel O’Roark and Nolan Hensley, PA-C on my podcast to talk about their new cash-based cardiology practice called Trinity Heart and Vascular Group.  Because cash-based practices are somewhat new to people, I wanted to share a few snippets from that conversation. I hope it will help you understand more about the cash-based practice and how it works for the patient, plus an inside look at the Trinity Heart and Vascular approach to patient care. 

Lots to share. Let’s dive in. 


The Cash-Based Practice 


Four things happened when I started Performance Medicine (cash-based) 17 years ago.  

  1. I became a better doctor.
  2. I had much more time to spend with my patients because I don’t use EMR, and I’m not searching for codes to try and get money from insurance companies. My only focus is on the patient.  
  3. I got better patients. Patients who cared about their health and truly wanted my help. 
  4. I have enjoyed my practice more. I’m not burned out like most doctors. Note: I’m almost 68 years old with no plans to retire! 

More and more practices are going cash-based for the same reason I did: to get rid of the unnecessary baggage you have to deal with in a regular practice (i.e., insurance, EMR’s, managers, etc.). In a traditional practice, there are a lot of people between you and the patient (middlemen). Not only are they soaking up profits, they are also taking up a ton of the providers’ time and telling them what to do! Often, the patient ends up being secondary. 

As a provider in the insurance model, you end up either working for insurance companies or hospitals, not patients. In a cash based practice, all you care about is getting the patient better. Note: The most helpful piece of knowledge you’re going to get is what the patient tells you. I listen to my patients. 

In a cash-based practice, you have to stay up-to-date and on top of things. You have to be better.  Most doctors, if they don’t know about something, will downplay it because they think they should know everything. But medicine changes, fast! I don’t practice anything like I did 5 years ago, much less 35 years ago when I started my practice. You have to keep up with things or you’re going to be way behind the times. Who would want to come see me if I wasn’t on top of things and did things in a better way? 

Note: By the time mainstream medicine comes around to approving something, we (usually) have already been doing it for years. 


Trinity Heart and Vascular Group 


Dr. Daniel O’Roark has been in clinical practice since the late 1980’s, and in this region more or less since 2005. He recently left what he calls the “corporate model” to do a cash-based practice. He and his partner, Nolan Hensley, PA-C, felt a real burden for outpatient medicine. 

There were a few reasons he chose to go cash-based: 

  1. He realized that outpatient medicine is where it starts. Most cardiac care starts in the office (of course there are a handful of patients that present to the ER with emergencies). 
  2. He also realized that many people have high, out of pocket expenses with their insurance. 
  3. It can take 6-12 weeks to get in to see a specialist, especially a cardiologist. 


The Foundation Is Lifestyle 


Good cardiology practice starts with lifestyle. The anti-inflammatory lifestyle is very important for heart health. There ARE pharmacologic approaches, which aren’t wrong, but it all starts with nutrition and lifestyle. Note: The foundation is lifestyle and trying to achieve ideal body weight. 

Most foods we eat are highly processed and pro inflammatory. Unfortunately, in our culture we’re always looking for a quick fix. One way to get away from this mindset is to take an honest assessment of your own health (where you are right now). 


Signs To Watch Out For 


Patients really do themselves a service by evaluating their own situation: 

  • “I’m 30-40 pounds overweight.” 
  • “I have risk factors.”
  • “I’ve used tobacco.” 
  • “My inflammatory markers are elevated.” 

Patients should be concerned with any new symptoms: 

  • Unexplained chest discomfort
  • Unexplained shortness of breath
  • Unexplained fatigue 

One common scenario is when women come in to see Dr. O’Roark and tell him that they were able to make their bed three weeks ago, but now when they do the same task they’re exhausted. Well, that is a clue that something might need to be looked into. Those signs are important because they are potential symptoms of progressive coronary atherosclerosis. It’s a common issue, and interventions can be done to help mitigate risk. 




There was a patient who came in to see me recently whose story I want to share with you guys. He is a 60 year old healthy male (thin, non-smoker, great blood pressure). He went in to see his family doctor and got some routine lab work done. The office said they’d call him when the results were back. A few days later, the office secretary called and told him that the doctor said, “you’re in danger of dying, we’re going to call you in some medicine” (which happened to be a statin). They told him to take the medicine and come back in three months. They never explained why he needed the medicine, or what the possible side effects were. Note: When he told me this I was dumbfounded. I couldn’t believe they would tell him his life was in danger. 

So, he came to me to get my opinion on it. I said, you must have pretty high cholesterol because that medication is a statin for high cholesterol. He brought in his labs and his cholesterol was 179. His HDL was great. His LDL might have been slightly elevated. If it was me, I wouldn’t have put him on a statin. I also would have ordered a CT Calcium Scan because of his age, but they didn’t even do that. Note: Cholesterol is a factor, but to me it’s a minor factor.  

What this primary care doc was practicing was “checkbox medicine”. This is something that came up in my conversation with Trinity Heart and Vascular.  


Their Approach 


At the end of the podcast, I gave a scenario to Dr. O’Roark that led him into sharing (in detail) their approach to patient care. I think this will really connect. 


A lady comes in with shortness of breath and fatigue. How would you start the workup on that? Would you run an echo? Would you do a treadmill test on her? 

Enter Dr. O’Roark: 

The first step is getting a good history and a physical. You know, we were all taught that years ago, but that seems to be a lost art. The history is very, very important (i.e., the assessment of risk factors). In our mindset, we’re getting broader than what we were traditionally taught. So, you start there. 

Of course, most of those patients, if not all of them, should have an electrocardiogram (baseline EKG). But then, you make your assessment. You make a formulation of what you think their risk is. What is their pretest probability of disease? What’s the likelihood this patient actually has obstructive coronary disease? And then you select the test. 

A lot of times a stress test is helpful. A stress test can be just a simple treadmill test. But there are patients, especially middle aged and older, where you’d want to couple that test with an imaging procedure, either a nuclear scan or echocardiography. We’re doing a lot of stress echos. There’s a lot of patient demand for that, because it’s a very good test. It has its nuances as compared to nuclear stress testing, but it’s much more affordable. And like you said earlier, we do have a different patient population. Patients that are more interested in their health and that type of thing. So, we have a lot more patients who are actually candidates for treadmill testing, plus or minus some imaging. 


Cash Based Cardiology Services 


Trinity Heart and Vascular does the basic electrocardiogram, nuclear stress testing, and cardiac monitoring. Palpitations are a common situation they see, making sure it’s not a serious arrhythmia. They offer one hour for an initial consultation and 30 minutes for follow up. In that time period, you can actually delve into those things! 

Remember, heart disease is the number one killer of Americans. The most common presenting symptom of a new heart attack is sudden death, so you can’t take this lightly. You want to know the status of your heart. 


Final Thoughts


There’s a better way to practice medicine, and it has nothing to do with insurance companies or non medical business people. That’s my message to my fellow providers and patients. 

Dr. O’Roark has wanted to do this model for 10 years but as a specialist, the timing just wasn’t right. They are now up and running and I’m very proud of them. Trinity Heart and Vascular Group is an amazing practice! I love their approach. 

Check them out at

Till next week.