‘How Much Is That Going to Cost Me, Doc?’


As a resident, about 50% of my clinic time was spent working with uninsured patients at a safety-net clinic. That was my crash course in health care costs. Most patients were “self pay” (a term I now despise!) for anything I ordered or prescribed.

In training, I also started to become more aware of insured patients’ costs as well. I quickly realized that just having a plastic card in your pocket does not lead to affordable costs or fair prices. I tried my best to help patients avoid surprise medical bills, but it was often an exercise in futility. I often felt helpless in answering my patients’ questions about costs of even basic stuff that was provided by my clinic and hospital system.

Wanting to provide my patients with more transparency, I started a Direct Primary Care practice shortly after finishing residency in 2011. My business plan and pricing structure had a radical mission: Make things affordable and tell patients what stuff costs…

By limiting overhead costs — which is pretty easy when you aren’t dealing with insurance hassles — I could make basic primary care services, including communications, clinic visits, point-of-care tests, and labs and office procedures very affordable if bundled in a simple monthly membership fee ($30 for kids, $50 for adults and $70 for seniors for unlimited amounts of service; with big discount for families).

Many of the patients who joined my practice were uninsured or carrying high-deductible insurance plans — not the “concierge” crowd that many of my colleagues predicted…

Being fully membership fee supported — without a need to profit from any ancillary services — we have been able to provide our patients labs and medications “at cost” of contracted rate. I was initially skeptical we could do that for things beyond basics, but the actual costs of most outpatient services are often astoundingly low compared to what I remembered hearing throughout my training.

With our lab contracts, we found an average of 50%-90% savings versus insurance-based prices and 80%-95% versus “self-pay” prices (if a patient gets billed directly by the lab). In fact, we purchased basic labs (lipid panel, hemoglobin A1c, TSH, metabolic panels, blood counts) so cheaply we decided to provide them at zero cost to our members; along with most point-of-care tests we perform (dipstick UA, EKG, urine pregnancy, rapid Strep)…

Doesn’t include a drug test.  That probably costs extra.

For medications, we used several tools to help patients find the best prices at pharmacies. We eventually realized the value of in-house dispensing of most common generic drugs. We offer patients meds at wholesale price with a very small markup to cover the pill vial, label, and bag. Our medications are usually 50%-90% cheaper than any pharmacy; a huge value and convenience to our patients. A good percentage of our patients save more money on medications each month than they pay in membership fees.

Most “common” or most “popular” generic drugs?  Because either way, that would include opioids, and I think the DEA frowns on doctor’s offices having an in-house pharmacy.  The drug war has created many profit motives for pharmacies, which obviously means corruption and illegal activity will follow. Maybe if you could prove to them that there’s no profit in selling drugs, they would let you carry opioids.

But you never know if you’ll have a problem with the DEA.  If you sell opioids, the DEA could be watching you right now.

Perhaps it’s not surprising that I see no mention of how this practice treats pain.  And I’ve read that the number one reason people see a doctor is because of pain.  If this practice just refers pain patients out to specialists, I’m not sure how much money is being saved by the patient.

How often do you need a specialist?  In my experience, by the time I see a doctor for something, it’s usually time for a specialist.  So, you go to this general practitioner, get tests done, and they send you to a pain specialist.  Who will then do the same tests over again, and add some more, just for good measure (and per the DEA).  Maybe you’ll get referred to yet another specialist, this time in neurology or physical therapy.

Somewhere down the line, you’ll be referred to a shrink.  Does Valium help you sleep?  See the shrink.  Obviously you need to talk to someone or else you’d be able to sleep.  Do opioids help your pain?  See the pain specialist.  Stress giving you a rash?  See the dermatologist.  Allergies bothering you?  See the ENT.

For diagnostic imaging, we have developed a local network of facilities with cash-friendly prices. It may seem unreasonable for patients to pay directly for things like CTs and MRIs, but we have found steep discounts for most things (i.e., $150 for ultrasound, $450 for MRI). We subcontract x-ray technical service with a local orthopedic group for $25-$35 per series and I don’t charge patients for my interpretation — not bad, considering our local hospitals charge $100-$300 for x-rays.

Ironically, even our patients with “good” insurance often spend less out-of-pocket on ancillary services with us by “paying cash.” …

I can understand why “good” is in quotes, but why is “paying cash” in quotes? If you don’t have insurance, you pay cash.  Even with insurance, you pay cash with deductibles and co-pays.  The question should always be, “What kind of service am I getting for my money?”  If I’m paying for a referral, that seems like a waste to me.

Even excellent primary care has its limits, so our patients do need to use their insurance when we can’t provide a needed service. This is still a tricky task for our patients, but thankfully, more organizations are taking up the cause of promoting transparency at all levels. Finding a baseline “fair” price for a given service is becoming easier with online tools. Recently a partnership between MedPage Today and ClearHealthCosts.com has started another transparency project to help tackle the issue…

I think I’ve shown just a few problems of a health care set-up like this.  Basically, you’re paying more money to have the ability to see the doctor whenever you need to.  As many times as you need to, although I’m sure there are some monthly limits.  And not too many evening or weekend visits either.

So, you have to keep paying for your insurance because you’ll still need it, but in addition, you’ll be paying for this service too.  Sounds like a concierge service to me.  A service not covered by insurance, just like some pain specialists.

For the first year of seeing pain specialist Joel Hochman in Houston, I was able to pay with Medicare. Then, he made me sign a form announcing that he was opting out of Medicare. Oh, he gave some good reasons why I now had to “pay cash” for his services.  But soon thereafter, he bought another new car.  And I can’t be sure I’m remembering this correctly, but I think he went to Venezuela for one of his “vacations” during that same year.  He took these vacations two or three (or four) times a year, bringing back photos, artwork, souvenirs, and lots of stories about his travels.

No, the question is not, “How much is that going to cost me, doc?”  The question is, “Which treatments (and services) will I have access to if I see this doctor?”  And how much cash will I have to pay the gatekeepers?

There, I feel better.  Thanks for reading. 🙂

5 thoughts on “‘How Much Is That Going to Cost Me, Doc?’

  1. OMG. Do you know what pisses me off now? I went for my annual woman’s check up and they now charge to get your results! Then I have to take more time off from work! Geez! The wedding in Burque was today! We didn’t end up going because my sister is in town. I’ll have a present for you when I go though ;). It won’t be a bug either.

    Liked by 1 person

  2. on a side note, you mention pharmacies located in doc’s offices….that is how all the mental health clnics here in az that are part of the medicaid system have it. my clinic has a primary care doc for all patients, located at the clinic and also has a pharmacy so you can get your meds before you leave if you want located inside the clnic. the idea is that if you are a mental health patient on medicaid, you only need to go to your mental health clinic to get all of your medical and mental health issues met. they also have a lab on premises for simple blood work orders.

    personally, i love the pcp i already have, so i don’t use the pcp at the mental health clinic. and i also love the pharmacy i have at my target store, so i don’t use the clinics’ pharmacy. i do use their lab, obviously, but i don’t have to…i can take it to any other free standing lab if i want.

    Liked by 1 person

    • I’ve heard that the Medicaid system is really good here in New Mexico, too. Sometimes it seems like the Medicaid system is better than the Medicare system. One of my neighbors was having some medical work done and I was surprised at how reasonable the costs were.

      Unfortunately, our governor really messed up the mental health system for Medicaid patients. Said that an audit indicated fraud within the system. The state stopped making payments and some clinics went under. Then it contracted out-of-state companies to fill in the huge gaps (from Arizona, I think). And now some of those companies are going under too.

      Turns out, the audit didn’t really show fraud. Governor Martinez just wanted to pay back these out-of-state companies for their political contributions, so she fabricated a reason to close down the existing clinics. And now our mental health system is a complete mess.

      Liked by 1 person

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