Why we list our prices.

The most-asked question at the open house we held in October — at the West End coffee shop two doors down from the practice — was not "do you take my insurance" or "what does it cost to join." Both of those came up, but neither was first. The first question, asked by an electrician's apprentice in his early twenties, was "if I joined, would I know what a blood test costs?"

The answer is yes. Yes, you would. We have a printed price sheet on a clipboard at the front desk; we keep it updated; we will hand it to you the moment you ask. The same numbers are on this website, on every protocol page, in the prices block at the bottom of the side-rail. You can read the cost of a CBC ($4.10), the cost of a Mirena IUD with insertion ($748), the cost of ninety atorvastatin tablets ($4.10), the cost of a 90-minute first visit ($0 if you're a member, included in the membership), and the cost of a sports physical ($0 if you're a member). You can read it before you book. You can read it from your phone. You can read it from a different state.

The young apprentice's follow-up question was the one I keep thinking about. "Why don't all of you do this?" The "all of you" was a wave of his hand at the rest of healthcare. The question is not rhetorical. It deserves a serious answer.

The technical answer

The technical answer is that the price of a clinical service in fee-for-service medicine is not, strictly speaking, a single number. It is a function of payor, plan, network status, deductible-to-date, copay schedule, coinsurance schedule, secondary insurance, capitation arrangements, prior authorisation status, modifier codes on the bill, and a non-trivial element of randomness produced by the claims-adjudication software at the payor. Two patients in adjacent exam rooms, getting the same metabolic panel done at the same lab, can be charged numbers that differ by an order of magnitude depending on which of the above variables are in play, and the clinic running their billing department often does not know either number until the explanation-of-benefits comes back six weeks later^[1].

The price-listing problem in fee-for-service medicine is not a willingness problem. It is an architecture problem. There is no single price to list. There are dozens, hidden inside a contracting structure that the clinic itself often cannot see. The federal hospital price transparency rule has begun forcing some of these numbers into the open since 2021^[2], with mixed compliance and stunning variability — the same MRI in the same building can show twenty different contracted rates depending on the payor.

Why DPC can do it

A direct primary care practice does not have any of those variables, because there is no payor. There is the practice and the patient. The CBC costs the practice $4.10, in batches of fifty, from the lab we send specimens to. We charge the patient the same $4.10. There is no markup, because there is no overhead structure that requires one — the membership has already paid for the time, the room, the clinician, and the fixed costs of running the practice. The only thing we are passing through is the variable cost of the test.

The same logic applies to every other line item on the price sheet. Atorvastatin 20 mg, ninety tablets: we buy it from Cuthbertson Pharmacy in batches; the per-pill cost is something on the order of four-and-a-half cents; ninety pills costs the practice $4.10; we charge $4.10. Mirena 52 mg IUD: $735 wholesale plus a $13 single-use insertion-tray cost; we charge $748. The arithmetic is not interesting. The interesting thing is that the arithmetic is doable at all.

Why it should be uncontroversial

It is a strange feature of American healthcare that price posting is treated as a marker of unseriousness. Every other small business in Duluth posts its prices: Northern Waters Smokehaus tells you what a sandwich costs before you order. The Lake Avenue barber chair tells you what a haircut costs before you sit down. The Duluth Trading Company tells you what a flannel shirt costs before you take it to the register. None of these establishments is treated as less serious for the disclosure. None of them are accused of "playing the numbers." They are running businesses; they are charging what they charge; the customer is making an informed decision.

I do not, frankly, have a charitable explanation for why American medical care has been the lone exception to this convention. The cynical explanation — that opacity is profitable for the largest players in the system — has the advantage of explaining the data, but I am wary of cynicism as a substitute for analysis. The structural explanation — that prices are genuinely undefined under the architecture I described above — is closer to the truth and has the disadvantage of describing how we got here without describing why we should stay.

Either way: we list our prices because we can, and because the version of medical care we want to provide is the kind that can be talked about in front of the patient before the test is run. The young apprentice who asked the question at the open house has joined the panel. He has, to date, paid for a CBC ($4.10) and a sports physical ($0, included). He knew both numbers before he got them done.

— EM