How to be an Authentic Doctor #24: Transparency


The healthcare system today is a shell game.  Nothing is what it appears to be.  I dare you to go to your local hospital and ask them “what is the cost of an appendectomy?”  You will not get an answer because Medicaid pays one fee, Medicare another, self-pay another and each insurer has their own back room deals in place.  How about your office?  Well, it’s still a farce.  If you work for a hospital then all you know is what’s called your work RVU (relative value units).  This is how what you do is converted to a measure of work which is then converted to a measure of payment which is how you are ultimately compensated.  Get it?

The patient may ask you how much a visit will cost and you really have no idea about the prices.  I went 15 years NOT knowing what each visit cost!  My Medicaid patients didn’t care because they didn’t have to pay.  I worked in a Federally Qualified Health Center for ten years so the hospital received a set fee (approximately $100 per visit) no matter what the visit was for.  After I switched hospitals these same Medicaid patients followed me and the new hospital received diddly.  My Medicare and insured patients had a price for each visit but that depended on what I coded the visit to be worth.  Even then, what was paid to the hospital for my work was totally unknown to me.  And it didn’t even matter to them!  Why?  Because we worked in a two hospital city where the big money was getting patients to use your hospital.  Each family doctor brings in about a $1 million dollars a year to the hospital he or she works for (in admissions, x-rays, surgeries, labs, ER visits, etc).   Add on facility fees and hospitals make a mint off of owning family doctors.

Do you see now how this is a shell game?   Actually, when I think about it, it is more of a Escher painting.  Everything is convoluted and gets you lost or confused.  Continuing on this metaphor pile-on, the system is like the inside of a baseball.  That sucker is wound tight and once you get in there it unwinds out of control and you can’t fix it.  That is our healthcare system.

So how can you be transparent when the world around is not?  Well, for one, you need to know how much things cost.  Most health plans are going high deductible and so patients are putting out the first few thousand or more out of their own pockets.  That means they are showing up less or arguing with you more about getting blood tests, following up for blood pressure checks, etc.  In fact, I have been seeing this trend for awhile and though it has made some patients better healthcare shoppers, most patients just don’t want to see you any more than they have to.  The insurers love this!   Once you know how much things cost and you try to explain to patients what may have to come out of their pockets (like you have all the time in the world to do this) then it is your job to put in the chart “patient refuses X (test or medicine or follow-up) and understands the risks of doing so”.  That is because most patients, in my experience, are delaying or refusing further work-up or follow-up visits.  And how sad is this?

My friends, pretty soon I will be embarking on the Direct Primary Care route where patients pay a small monthly membership fee and I walk away from the insurance world.  Though I still won’t be able to tell them the price of services outside of my office, I will have time to help them negotiate and/or even game the system in their favor.  Since following up with me will cost them no more (I won’t have copays), then I think I can do a better job with compliance with medications, treatment plans, etc.  The bottom line is that all I can possible control in my life is my life.  Working for the hospital made me feel like I was personally transparent.   Now I feel affirmed and only my prices are transparent.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected]

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2 Responses

  1. Kurt says:

    Only problem with D.P.C. is one would still have to do their homework as where to locate. Plus if they don’t have any coverage for “expensive tests” one will get, “Oh, you take care of me doctor, I don’t need that pricey
    specialist.” If the poop hits the fan, could spell trouble.
    Of course, if you end up in an area with plenty of patients who go for that model and have coverage for the pricey tests and consultants when needed, looks like it would be a more satisfying practice. If they are paying you money directly, might be more inclined to follow your advice. Best of luck.
    I’m stuck with 7 more years of pain before I can walk off into the sunset of retirement. Suffice it to say, I WILL NOT be doing any “volunteer” medical work because it costs too much for the “maintence of certification”. Kurt

  2. Ray says:

    Strength and honor.

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