One of the hardest things to get used to as a DPC Doc is talking to my patients about prices. When I was a fee-for-service Doc, prices and costs were rarely a part of the conversation in any meaningful way. Sometimes patients would ask me about how much a test or medication would cost, and I would simply shrug and say “I’m not sure, but I don’t think it’s too expensive.”
The final prices in healthcare are usually hidden under intentionally obscure layers. Is the service preventive or diagnostic? Has the patient met their deductible? What is the co-insurance or co-pay? Is the service even a covered benefit? Most patients don’t find out about the final price until they receive a bill, often for a service they have already received and now they’re on the hook for.
I’ll never forget the case of the Pap smear that put my patient into collections – a Pap smear that I recommended. My patient was a 65 y/o grandmother who had been avoiding her Pap smear for years. Concerned that she was not up to date with her cancer screening, I urged her to have her Pap smear completed. “Ms. Jones, you’re 65. If this pap is normal, then we’re done for life and we’ll know your cervical cancer status.” Like a good patient, Ms. Jones trusted me as her physician and had her Pap smear done. Thankfully, it was negative.
Then came the $400 Bill.
What I didn’t know at the time was that her Medicare plan did not cover HPV co-testing with her Pap smear – despite medical guidelines supporting HPV testing. I had never had a pap with HPV denied by insurance, and never had any reason to suspect that my recommendation would leave her with such a hefty bill. My recommendation put my patient, a 65 y/o grandmother on a fixed income, into collections. I was devastated for her, and there was little I could do to remedy the situation for a service that was already rendered.
Situations like these fuel moral injury in medicine. I was not acting like a greedy doctor – I never saw a dime of her $400 bill. I was simply following the recommended cancer screening guidelines, but my suggestion caused real harm to my patient. Unknowingly, I violated my oath the “first, do no harm.”
Fast forward to my life in Direct Primary Care. I recently had an uninsured patient who needed her Pap smear. After discussing the risks and benefits of cervical cancer screening, I nervously followed with telling her that the price of the pap without HPV was $33 and with HPV would be $88 (yes, that’s right – the pap with HPV was more than 75% less than what Medicare charged my last patient). At first, it felt uncomfortable and even taboo to introduce the element of price into the conversation about her medical care – we’re not trained to discuss prices. However, this conversation armed my patient with the information she needed to make an informed choice about her care – and she opted for the pap with HPV.
Price Transparency is part of the magic of Direct Primary Care. I’d much rather have a patient decline my services due to the cost rather than lead another patient into financial ruin by denying them informed financial consent.
It may seem hard at first, but having the discussion about prices actually empowers our patients and gives them true choices in their care. While I can’t undo the financial harm I caused my first patient, thanks to Direct Primary Care, I can make sure that I never financially mislead another patient.