KANSAS CITY, Mo. — You go to the doctor. You pay the doctor.

What could be simpler?

Following a practice that would have been typical in the 1960s, some doctors have decided not to accept health insurance.

Patients of these doctors pay the whole charge — at the time of the visit or after the doctor sends them a bill. For patients who have health insurance, it is up to them to get reimbursed by their health plans.

Doctors who go this route — an estimated 35,000 or so across the country — say they gain autonomy and independence by opting out of an increasingly dysfunctional health-insurance system.

"It keeps me working for the patient. I don't have to answer to the insurance company first," said John Dunlap, an Overland Park, Kan., internal-medicine physician who has never worked through insurance companies since beginning his practice in 1980.

Despite the allure, those deciding to work outside the health-insurance system are more of a trickle than a flood. Healthcare industry studies suggest that roughly 90 percent of doctors are affiliated with a managed-care plan, and those numbers have not moved much in recent years.

"Our physician-turnover rate in our networks is significantly less than 1 percent," said Susan Johnson, a spokeswoman for Blue Cross and Blue Shield of Kansas City. "We just don't see many physicians leaving our networks."

Patients have their own reasons for agreeing to such cash-and-carry arrangements — but it is generally not about saving money.

It is the "quality of care, the personalized attention," said Jari Holland Buck, a patient of Jane Murray, a Mission, Kan., doctor who does not accept insurance payments.

Murray is medical director of the Sastun Center of Integrative Health Care. She practices what she describes as "open-minded" family medicine — conventional treatments with a heavy emphasis on nutrition, lifestyle and other nonpharmacological treatments.

Murray stresses the importance of the doctor-patient relationship.

"I don't want to be the intermediary between the payer and the patient," she said. "When the person has a direct financial covenant with me, it's clear that they're my boss."

Why do this?

Going to a doctor who does not accept insurance may actually cost patients more money because the doctors work outside of any insurance network.

"I establish my own fees, based on reasonable charges," Dunlap said.

Chuck Wiedenhoft, who had an appointment in March with Dunlap for a physical, said he would probably save money if he went to a doctor in his health-plan network.

The 56-year-old Overland Park resident chooses to go to Dunlap for peace of mind.

"It's the confidence in the quality of the service I get, and the confidence I have in him as a doctor," he said.

Longer visits with the doctor are a draw for patients like Mike Palmer, who has been going to Dunlap for three years. The 60-year-old Leawood, Kan., resident is retired but still does consulting for his former employer, which provides him with health coverage.

Palmer said his physical in March with Dunlap took about an hour.

"Besides going over my test results, he asked about my family and how I was doing emotionally, how I was doing exercisewise," Palmer said.