As a journalist who writes frequently about health care, I was intrigued by the question Robert Edsall raised in his editorial in the February 2006 issue: “...what would happen – and how would insurers, employers and the government respond – if a significant minority or even a majority of practices went cash only? Is that even possible?”

I think I can answer his questions with some confidence. The insurers would fight the move tooth-and-nail because they would see it for what it is: an attempt by doctors to go around the insurers to market directly to patients. Keep in mind that insurers act as marketers for physicians. In return for bringing business to the doctors, the insurers pay doctors at wholesale and re-sell their services at retail via insurance premiums. Business-wise doctors, as you show in the February issue, are coming to recognize that they can do much better financially if they can attract patients who will pay retail rates.

Employers would welcome the trend. Employers hate paying all or part of health insurance premiums, and for good reason: It’s a huge, and fast-rising, expense, and their competitors in China, England, Germany and India aren’t saddled with this expense; the government pays, or else patients pay.

I suspect the government would back the insurance companies because the government hates change. Moreover, the insurance companies are big donors to congressmen, senators and the president.

It’s all part of a power struggle. For the past half-century, the insurers have been winning the battle, hands down. But there’s nothing that says physicians can’t fight back, and win. After all, isn’t it the opportunity for such cat-and-dog fights that makes America great?

Kudos to your reporting on Dr. Brian Forrest and his success in establishing an affordable, effective, cash-only practice [“2,500 Cash Paying Patients and Growing,” February 2006]. His practice sounds remarkably similar to Doctors Care, a practice established in Calhoun, Ga., by a friend of mine, Todd West, MD. The principles of low overhead, flat fees, no third-party contracts and payment at the time of service have been tried and shown to be true by Dr. West, and now Dr. Forrest.

These principles are key for the sustainability of an independent primary care office. My interest in them is that they return the physician to the moral foundation upon which the Hippocratic ideal was established: trust and excellence brought about by free thought and free association between individuals in a purely voluntary relationship.

Since its publication I have scoffed at the “Future of Family Medicine” project as a lot of well-meaning academic drivel that emphasizes physician obligations and de-emphasizes payment. The approach of Dr. Forrest and Dr. West is the true future of family medicine if there is to be one at all.