Medical Credit Cards for Self-Pay and Insurance-Based Out-of-Pocket Costs in Academic Plastic Surgery

INTRODUCTION Rising out-of-pocket (OOP) health costs in the United States have created a market for third-party “buy now, pay later” financing such as medical credit cards (MCCs).1,2 MCCs are marketed to improve access to care by enabling patients to spread payments over time. However, MCCs often carry high interest rates and penalties, raising concerns about the financial literacy required for patients to navigate them.3,4 Among MCCs available in the United States, CareCredit occupies a prominent position, in part due to its endorsement by multiple major medical societies. Although originally developed for elective, self-pay, and cosmetic services, CareCredit may now be increasingly accepted for reconstructive care that has historically been “covered” by insurance.5,6 Reports of nonprofit hospitals steering patients toward CareCredit instead of in-house payment plans or financial assistance highlight potential ethical issues. Patients may feel compelled to take on high-interest debt to access necessary medical care. To understand practice-level willingness to accept CareCredit for either insurance-based or non-insurance-based procedures, we conducted a secret-shopper study of US academic plastic and reconstructive surgery (PRS) practices. METHODS Between May and July of 2025, investigators (S.A.S. and A.J.D.) contacted all academic clinics affiliated with a PRS residency program (n = 106) using a standardized script (Supplement Text 1, https://links.lww.com/AOSO/A591). Investigators posed as family members of patients seeking breast reduction or gynecomastia surgery. These procedures were selected because they are common as either aesthetic (self-pay) or reconstructive (insurance-based) procedures, depending on the clinical context. During the calls, staff were asked whether CareCredit could be used to finance the procedure if insurance denied coverage or to pay for residual OOP costs, allowing comparison of policies for self-pay versus insurance-based scenarios. Additionally, we reviewed the CareCredit website to see whether its public directory matched information communicated by practices. The primary outcome was whether clinic staff reported accepting CareCredit. Secondary outcomes included the availability of financing for self-pay versus insurance-based care. Hospital characteristics were obtained from the 2023 American Hospital Association annual survey. Analyses were performed using Stata, Version 18 (StataCorp LLC, College Station, TX). Study findings were reported per Strengthening the Reporting of Observational Studies in Epidemiology guidelines. The study was deemed exempt by the Institutional Review Boards at Northwestern University and Mass General Brigham due to the nonhuman subjects designation. RESULTS One hundred six PRS practices were called, with 100 included in the final sample (six were not accepting new patients or did not offer aesthetic procedures). Forty-two percent (n = 42) accepted CareCredit as a form of payment, and 40% (n = 40) accepted it for aesthetic (self-pay) procedures, while 27% (n = 27) allowed patients to use it when paying OOP costs for reconstructive (insurance-based) procedures (Table 1). Only 2% (n = 2) of clinics accepted CareCredit for reconstructive, but not aesthetic, procedures. TABLE 1. - Characteristics of Institutions Offering Versus Not Offering CareCredit No Yes Total (N = 57) (N = 42) (N = 99*) Accepts CareCredit for aesthetic procedures – 40 Accepts CareCredit for reconstructive procedures – 27 Census Regions Northeast 18 (31.6%) 10 (23.8%) 28 (28.3%) Midwest 14 (24.6%) 9 (21.4%) 23 (23.2%) South 15 (26.3%) 19 (45.2%) 34 (34.3%) West 10 (17.5%) 4 (9.5%) 14 (14.1%) Urbanicity Rural 1 (1.8%) 1 (2.4%) 2 (2.0%) Urban 56 (98.2%) 41 (97.6%) 97 (98.0%) Ownership type Government 18 (31.6%) 10 (23.8%) 28 (28.3%) Nonprofit 39 (68.4%) 32 (76.2%) 71 (71.7%) Number of beds <200 beds 1 (1.8%) 0 (0.0%) 1 (1.0%) 200–399 beds 3 (5.3%) 2 (4.8%) 5 (5.1%) 400+ beds 53 (93.0%) 40 (95.2%) 93 (93.9%) Hospital admissions 35,198.6 (17,088.1) 37,978.1 (20,448.1) 36,377.8 (18,539.0) Inpatient days 241,004.3 (103,975.5) 254,462.5 (140,846.3) 246,713.8 (120,506.4) Outpatient visits 1,170,439.8 (874,503.9) 1,241,723.3 (1,283,879.5) 1,200,681.3 (1,062,013.3) Surgical operations 39,123.0 (31,394.9) 35,092.5 (26,452.4) 37,413.1 (29,325.3) *Our study initially included 106 academic plastic surgery clinics affiliated with PRS residency programs. Six clinics were subsequently excluded from analysis because they were either not accepting new patients or did not offer aesthetic procedures. Although our final sample comprises 100 hospitals, the table displays data for only 99 entries. This is because New York-Presbyterian–Cornell and New York-Presbyterian–Columbia are combined under a single American Hospital Association (AHA) listing for the New York-Presbyterian system. Discrepancies existed comparing clinic calls to the CareCredit website. Nineteen percent (n = 19) of clinics were listed on the CareCredit website. Two percent (n = 2) of those stated they no longer accept CareCredit due to changes in hospital policy, while 25% (n = 25) of additional offices not listed on the website reported accepting this financing option. We also inquired about practice-level financing. These options were consistently available for insurance-based care with policies governed by central finance offices. Only a small minority of practices (10%, n = 10) reported case-by-case consideration of payment plans for aesthetic procedures, without standardized terms. DISCUSSION In this national secret-shopper study, 42% of practices accepted CareCredit, including 27% for insurance-based procedures. Notably, less than one-fifth of these practices were listed on the CareCredit site, while an additional 25% confirmed acceptance over the phone, suggesting broader utilization than previously recognized.6 For some patients, access to financing options may be a rational or empowering decision. Yet, the increasing use of CareCredit for reconstructive care raises concerns that patients are taking on further debt at high interest rates to obtain medically necessary care rather than discretionary aesthetic services. In this context, MCCs may shift the financial burden of essential care from institutions and payers onto patients, amplifying financial toxicity rather than simply itating access. Our study underscores the need for greater transparency and oversight surrounding MCCs. Study limitations include our focus on academic practices, which limits generalizability to nonacademic settings. Additionally, data were obtained through interactions with front-desk staff, which may not capture variability in institutional billing policies or downstream patient experiences. Future work should explore patient experiences and financial outcomes, and the extent to which CareCredit is utilized.