Years ago, I hired a carpenter to build a deck in my backyard.  This scraggly guy showed up with a pencil behind his ear, a spiral notebook and a tape measure.  I told him what I was looking for, what kind of wood and how big I wanted it to be.  He made two or three suggestions, we agreed and then he went to work measuring and taking notes.  Fifteen minutes later, he handed me a piece of paper with how much it would cost.  Then he was gone.

In two days, he called me and said he would like a payment for the lumber and told me how much it was.  I sent it to him.  Five days later, he showed up with the lumber-already cut.  This guy knew what he was doing.  

At the time, it blew my mind that he showed up with all of the lumber already cut, ready to assemble/nail.  As I look back, I realize that this man, like so many others in a true market economy, did the most amazing thing, the very same thing we have done at our surgery center and what so many hospitals say is impossible:  he gave me an up front price.

Now you want to say, “Smith!  Building a deck isn’t surgery.”  Contractors like this man, however, have run into unanticipated problems that make certain jobs more difficult than others.  Experienced contractors anticipate these future problems when evaluating a potential job, factoring this into their price.  Most of the time they get it right.  Sometimes they get it wrong.  If their error rate isn’t factored into their price, they go broke.  If their error rate is low, they are able to be much more competitive in the marketplace.

I think of this carpenter often.  I certainly had him in mind when I formulated our internet pricing.  I knew that some cases would be more difficult than others.  I knew that we would probably lose on some and make a little better marginal profit on others.  This is what all businessmen do every day in every sector of the economy-except healthcare, it seems.

Eleven years ago, we began construction of the large facility in which we now work in Oklahoma City.  The general contractor and the architect gave us a number.  Not an estimate.  A number.  They had factored in to their calculation variables that could represent setbacks, still allowing for a reasonable marginal profit.  I had been providing occasional prices for the uninsured and poor having surgery for years by this point, but found the contractor’s confidence in what our new facility would cost, fascinating and incredible.

When I think about the number of times I have heard the hospital folks say that fixed, upfront pricing in health care is impossible, I think about these builders/contractors.  I think about my carpenter.  Having provided transparent pricing to surgical patients, I have found that in some cases I was wrong.  In some cases I was too high, in some cases I was too low.  Adjustments were made.  Not at the expense of the patient, though.  

Transparent pricing is necessary for any concept of value to have meaning.  Transparent pricing is necessary in order for appropriate signals concerning scarcity or abundance/surplus to have meaning.  Non-transparent pricing is a hallmark of command economies, as Professor Robert Higgs explains in his brilliant book, “Crisis and Leviathan,” one which I highly recommend.  There can simply be no meaningful competition when the prices aren’t transparent and known up front.  

Not all medical facilities need to exhibit transparent pricing in order for a competitive and market economy to emerge in health care.  Indeed, our internet pricing has allowed individuals to leverage their local medical facilities, as otherwise they would have gladly jumped on a plane and come to us for surgical care, the price for which was quantifiable.  In spite of big hospitals’ attempts to denigrate this idea, they have found themselves in a competitive environment, whether they like it or not.  Whether patients are willing to fly to Costa Rica, New Delhi or Oklahoma City, they have a price in mind and the local hospitals are shoved against the wall with this pricing, forced to explain why they are ten times more expensive while simultaneously claiming to not make a profit.  In the absence of any evidence that they are ten times better, their position (6-10 times more expensive) is a weak one.    

In Oklahoma City, upfront pricing is available at our facility and several others.   A group of gastroenterologists, a group of oncologists, a group of radiologists with a breast imaging center, a group of cardiologists and cardiac surgeons with a physician-controlled heart hospitals, a group of orthopedic surgeons-they all have their pricing configured.  A tertiary hospital has recently joined in this effort, providing upfront pricing for inpatient procedures too complex to complete at our facility.  This is a very exciting development.  

Since hospitals are responsible for the vast majority of medical costs in this country, slashing these outrageous charges brings incredible savings without even touching physician pay.  Since we own our facility, we are content with solid fees for our professional services with no desire to plunder and bankrupt our patients with gigantic facility fees, unlike the so-called “not for profit” hospitals.  We actually act more like a “not for profit” entity than those claiming this tax-free status.

Hospitals and their shills who claim that up front pricing can’t be done, know that it can be done.  They just don’t like what that means for them.  They want to work on a “time and materials” basis, a recipe for waste and inefficiency, as waste and fraud generate more revenue with this model’s lack of accountability.  The more materials used (with their outrageous mark-ups) the more they make.  Forcing medical facilities to be transparent with legislation is a mistake, I believe, as this is a violation of the “non-aggression principle” and also will more than likely provide legislators the opportunity to sell exemptions, with little or no  transparency resulting.  With the movement for medical price transparency on a roll now, better, I think, to let the much more unforgiving market deal with those who refuse to be transparent.  Those who won’t divulge prices will lose out to those who will.  

At The Surgery Center of Oklahoma we will continue to advocate a free market in medicine, one that’s possible only when accompanied with and characterized by transparent pricing.  We will continue to encourage and recruit others to join us in this effort, one that will likely bring such significant health care price deflation, that the “crisis” the government is attempting to create in order to usher in single payer, will be delayed indefinitely if not thwarted completely.  

As I told someone recently, “..the genie is out of the bottle.  Price transparency is here and here to stay, whether the government or the health cartel they have created like it or not.”  My partners and I are proud to have played a role in the transparency effort, one which we believe will bring price sanity to surgical care in particular, but ultimately to the pricing for all medical care.

G. Keith Smith, M.D.