Revolutionizing Surgical Cash Pay Healthcare: Dr. Keith Smith's Journey with Surgery Center of Oklahoma

In this special episode of My DPC Story, Dr. Keith Smith, a board-certified anesthesiologist and co-founder of Surgery Center of Oklahoma, shares about his pioneering facility in price transparency within healthcare. Dr. Smith discusses his transition from traditional insurance-based anesthesia to establishing a surgery center that offers clear, upfront pricing for various medical procedures, bypassing the complexities and high costs associated with insurance. The episode explores the journey to starting the facility, how they maintain quality while keeping costs low, and the advantages of the free market medical model. The conversation also highlights the potential for self-funding in both individual and employer-sponsored healthcare plans, and the upcoming Free Market Medical Association conference aimed at educating and inspiring medical professionals. Listeners are encouraged to rethink traditional healthcare models and consider the benefits of cash pay healthcare and price transparency.

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Transcript

Maryal Concepcion MD: 1:02

Primary care is an innovative, alternative path to insurance driven healthcare. Typically, a patient pays their doctor a low monthly membership and, in return, builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the my DPC story podcast, where each week you will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model. I'm your host, Marielle Concepcion, family physician, DPC owner, and former fee for service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care, direct primary care. Dr. Keith Smith is a board-certified anesthesiologist and co-founder of Surgery Center of Oklahoma, a physician owned outpatient facility pioneering price transparency in healthcare. Since 2009, Surgery Center of Oklahoma has posted all-inclusive surgical prices online, attracting uninsured patients, Canadians, and self-funded employers seeking affordable, high quality care. A passionate advocate for free market healthcare, Dr. Smith co founded the Free Market Medical Association, or FMMA, to connect patients, physicians, and employers looking for transparent pricing. His innovative approach has gained national recognition with features in Forbes, the New York Times, ABC News, and appearances on CNBC, Fox News, and the John Stossel Show. As Surgery Center of Oklahoma's CEO and Medical Director, he continues to challenge the status quo, proving that competition and transparency can drive lower costs and better patient outcomes. This is an exciting special episode that we are doing with Dr. Keith Smith of Surgery Center of Oklahoma. the last time I saw him in person, I literally got a text from Dr. Kissy Blackwell, who's a DPC physician in Wichita Falls, Texas. And she said, if you see Dr. Smith at Rosetta Fest, make sure that you tell him that, and filled in the details. And so I tapped Dr. Smith on the, on the shoulder and was able to say, look, Dr. Smith, this is coming from Kissy Blackwell. And he said, oh my goodness, amazing. Thank you for telling me. He knew Dr. Kissy Blackwell and he knew of her patient. And so I, I want to mention that starting this episode because in a world where transparency is not a thing for our patients, transparency is very hard for even us as physicians to know how we're getting paid. Dr. Smith created a different pathway. So welcome, welcome Dr. Smith.

Keith Smith MD: 3:42

Thanks for having me.

Maryal Concepcion MD: 3:43

A lot of people know the surgery center of Oklahoma, but that's about it. They don't know that you have necessarily pricing on your website. They don't know the history of how you created a surgery center where patients can even stay overnight if they need to with cash pricing, no insurance accepted in a world where people assume that you cannot have a physician known facility. So start us off with telling us about your transition from regular insurance based anesthesia to what you have today.

Keith Smith MD: 4:15

Well, thanks for the opportunity to, to tell this story. I, I think about this story more often than, than I have in the past with some nostalgia because. I don't think I realized at the time when Dr. Steve Lottier and I started the facility how radical what we had in mind really was but I was recruited to Oklahoma City to a traditional anesthesia practice, focusing on cardiac anesthesia primarily. And I got started in 1990. That was very busy, very successful, well liked, had all the anesthesia I could say grace over. It's very, very busy practice. And everything was going well. And then in 1992 the federal government inflicted the Resource Based Relative Value Scale Part 1 under George Bush the Elder. They, the folks, the arrogant folks at Medicare thought that they could place a price for all of you too young to know this story. They thought they could place a price with the help of some folks at Harvard on every single physician's service. That, that was available and the AMA was complicit in this, in this really conspiracy. And that's where we got all these codes and these code books. That's where all of the, the CPT coding and pricing came from. And if you wonder why Medicare pays you so much money for an office visit or so much money for rotator cuff repair. That's where it came from. As an anesthesiologist, I was part of the hospital based group of victim targets that Medicare knew they could abuse with with pretty good confidence that they could get away with it. So radiologists, anesthesiologists, pathologists and emergency room docs were there. four of the most brutally victimized by this plan. It's to give you an idea of real numbers. When I started in 1990, I was paid about 1100 for an open heart surgery that I provided the anesthesia for. After round one of R. B. R. V. S. That went to around 550. So it was cut 50%. Physicians did what? You would think they would do. They just jacked up their prices for everyone else to make up for this. This draconian cut not satisfied that they had cut enough. R. B. R. V. S. Round two was inflicted, which cut those prices in half. So the last open heart surgery for which I've provided an anesthesia anesthetic, I was paid 285 about 287. The last TotalMe Medicare beneficiary I provided anesthesia to, I was paid 78. And I'd read enough economics by then to know this was not personal. These were prices signals in the marketplace. And, and I also knew that no matter how smart they thought they were, they were not going to get this right. When you inflict pricing from top down, it's always wrong. It's too high or too low. If it's too low, you get shortages. And if it's too high, you get surpluses. So I thought it was incumbent upon me to respond with a rational, logical signal of my own. And so I quit. I decided I was going to be a shortage, and I didn't quit seeing Medicare patients. I was an anesthesiologist that worked in seven big hospital systems, and I continued to provide anesthesia care to the Medicare patient surgeons that I worked with took care of. I just didn't file any claims. So I walked away from any dealings at all with Medicare. Didn't worry for a moment about any foregone revenue is one of the most liberating things I've done. In my life, at that time, probably the most liberating thing I'd ever done. But I began to think about pricing, and I, and I also began to notice the hospital administrative staff was ballooning. So physicians were getting just hammered on their fees, and hospitals were growing. There was a crane in front of the emergency room of everyone where I worked. I also noticed that surgeons I worked with were increasingly denied. The supplies and innovations that they, that they needed to perform surgeries successfully in a high quality way. And looking back, all of this denial was simply to maintain the false narrative that these, poor mouthing hospitals, these not for profit hospitals supposedly were going broke. In the old days, before electronic health records there were paper records, and I'm old enough to remember going to the medical records department, and you could ask for a chart, and you would get a paper chart, and you would open it up, and on the left side of the chart, Was all of the financial information and on the right side of the chart was all of the clinical information. So you could easily flip through these pages and see that patients were increasingly being brutalized financially by these hospitals. So. Physicians weren't making nearly as much money, I would argue, not paid fairly for service that they provided by any, by any measure. Hospitals were making more and more money and, and I realized I was an accessory. I was an accomplice I was aiding and abetting and enabling the big hospital systems all the, who all the while claimed to not make a profit. bankrupt patients for carpal tunnel release, tonsillectomy. Rotator cuff repair. You name it. And I didn't feel like that. That was consistent with my values. I was raised in a Christian home. We thought the golden rule meant something mutually beneficial exchange was just part of dealing ethically with other human beings. And that was what drew me to medicine. It was it was going to be, a lifetime full of mutually beneficial exchange where I You know, did my best to provide great service and met, gratitude and reasonable payment on the other end. And then this was not consistent with any of that. So I walked away. Steve Lantier, very like minded anesthesiologist. He and I decided we weren't going to do this anymore. We were too young to just be miserable the rest of our careers. And as anesthesiologists, the only way we could really secede was to have and own and control our own facility. And so in May of 1997, we took over the operations of a failing burnout surgery center. And that was the beginning, really, of the Surgery Center of Oklahoma. And our mission was real simple. We were going to provide the highest quality care possible at a reasonable price. Patients were going to know how much they were going to pay us prior to arrival. And we would never accept a dime of money from the federal government. So, we got started and we were, we were busy, really, from the very beginning, and quoting prices over the phone to patients from the very beginning. And that really was how we started.

Maryal Concepcion MD: 11:54

And, I, I will re quote you the fact that you were thinking logical and rationally when you were deciding to leave the system is, as a DPC physician who has also left the system, Absolutely on point. And I think that it really calls out when we are working in a fee for service system and we're accepting all insurances and we feel inclusive, I just had this conversation with a medical student and a first year family medicine intern today or yesterday that when you're billing, you don't actually know Especially in fever service, how much you're, making a dent in the patient's pocket. And as an outpatient doctor, I'm not a surgeon. I'm not an anesthesiologist. So, the things that I'm talking about are like a lipid panel, but a lipid panel that costs 500 because of the markups is going to make a very different dent in a person's pocketbook compared to a transparent cash price of 8 or less. And so I do think that you, you make a very valid point in that. Sometimes we don't know what we don't know, but you are educating people, all of the, all of the physicians who have shared their direct primary care story in this podcast, are educating people that there is actually a very, very big way of, of making the healthcare system profitable and at the expense of our own health as patients and as a, as a nation. So let's talk about after you guys took over the surgery center, which became the surgery center of Oklahoma. And you had to get patients somehow. It's tell us, tell us about that first patient that came, to you guys, because having a center is one thing it's like having a DBC clinic is one thing. And then when somebody calls you and you're like, Oh my gosh, I don't actually know the price of this or that you guys went through that yourself. So tell us about how. It really started the culture from patient number one as to how pricing pretty much hasn't changed except for very, very few exceptions to this day.

Keith Smith MD: 13:50

Well, and again, the success of the Surgery Center of Oklahoma now and even on our first day was a manifestation of the dedication to quality that Steve Lantier and I embraced. So when we walked out, surgeons walked out with us. They, they brought their patients to us and Steve and I are both cardiac and pediatric fellowship trained and we loved doing pediatric anesthesia as much or more than doing cardiac anesthesia. So, the, the pediatric surgeons brought their pediatric patients to us because. We loved doing it. We enjoyed doing it. We were good at it. We still do a lot of pediatric anesthesia and it's my favorite, favorite thing to do. We also were maybe more accomplished than some of the other members of my anesthesia group at performing regional anesthesia to keep orthopedic patients comfortable. So when we walked out, those surgeons that we were connected to walked out with us. I still remember the first case we did and it was a patient that a surgeon brought to us. The very first case we did on May 28, 1997 was a six month old that needed a nasal lacrimal duct probe. And people thought we were crazy for opening our own facility. But they knew we were crazy when the first patient we operated on was only six months old. And we just had one one success story after another. The first week we were opened, we received a call from a patient with a breast mass. who wanted to know how much we would charge her for excision. And I didn't know the answer to her question, but I figured I could give her an answer. So I put her on hold, called the surgeon and got his fee. I figured it would take about 30 minutes, a minimum of supplies, 30 minutes of my time. Had new after another, another call while she was on hold, found out the pathology fee and then quoted or 1900 over the phone. And when I said 1900, she said, for what? And I said, well, for everything. And she said, well, the hospital down the street from you quoted 19, 000 just for the facility and this 10 to 1, 8 to 1 ratio of what we could charge. and be profitable was was something that we saw then and we still see now. And it was very gratifying after, we performed that case and I sharpened my pencil. We made money. And so the prices I quoted all over the phone, to your point, in 1997, were the same prices that I posted online in 2009, except for the ones that I had lowered, and I did not change those prices until, I think it was 2021 when inflation on the supplies we needed to purchase just got the best of us and we couldn't absorb it anymore. So, the idea that prices are out of control, the spiraling price inflation in medical care, some of that is true in pharma. But for the supplies that we buy to perform surgeries, that really has not been a huge issue. It has, it has lately, but historically not a huge issue.

Maryal Concepcion MD: 17:17

tell us now about What things do you offer? Because, I'm sure people's minds are already being blown away by your first patient was a six month old little one, and then you had a breast mass removal, like we are recording the, this during the, the virality of Dr. Elizabeth Potter, who is fighting and fighting and fighting about just getting her patients good care and whether a person owns their facility or not, because, many of us who went to medical school have rotated in private surgery centers, insurance is usually still accepted. And that is a difference at your facility. So tell us about what services are offered and how can patients just as easily as they shop for, something at an online store for, a backpack or, a backpack for a kid's first day of school to a lunch pail like How can they shop for surgical procedures?

Keith Smith MD: 18:08

We we do a wide variety of surgeries. There are 130 physicians on staff at our facility do ear, nose and throat surgeries, orthopedics, general surgery, gynecology, urology oral maxillofacial reconstructive surgery, podiatry. Pediatric ophthalmology, oculoplastics. What am I leaving out? So, we do total, we do total joints, knees, hips, shoulders. We perform cochlear implants. On little babies. We do a real wide variety of procedures and that the way people typically find us online is through a request a specialist tab that's on our website and those emails come directly to me. And so if someone is looking for a surgeon to repair their rotator cuff or remove their child's tonsils. Then I connect them with the surgeon that I believe is really most appropriate for the job, who I know is available, who I know is going to reach out to them and make contact. That's how I knew all about Kissy Blackwell's patient that you'd asked me about, because that referral came to me, and then I assigned it to a surgeon. So I knew, I review all those records and so we know, medical, From a medical standpoint, I'm the medical director and I know, I know about all these patients that are coming through

Maryal Concepcion MD: 20:17

and, I just think of the silliness of, this idea that physicians can't own their own facilities because, clearly we, we don't know about actually taking care of patients, even though we're the ones, not the admins who went to doctor school. But I, I love that. It really highlights that when you are working directly for your patient, you are invested in making sure that they have good care because they are your business card walking and telling their neighbors. And so, I think that it really it is a, it is an excellent. in a way for people to, in the frustration that we have with bankruptcy related to medical cost ballooning it is a way for patients to just transparently shop. And I mean, even in rural Northern California, I have sat inpatient visits. Popped open my web browser, found a flight to Oklahoma City, went on your website, because it's just surgerycenterok. com, so if you have not been there, definitely bookmark that, and it'll be in the accompanying blog with this podcast, but there's literally even in A map of the body and you can click on like, where are you needing surgery? You guys have always provided, before you had the website you had on the phone pricing, but you guys have transparency that people deserve because you are able to say, what is the actual cost of these things without the markup from the third party pair? And so.

Keith Smith MD: 21:42

When I posted the prices in 2009, I had three goals in mind. One, one was so patients with sticker shock, whether it's high deductible, no insurance, member of cost sharing ministry, self funded plan so they could better find us and, and not have to face bankruptcy for what is a minor surgical procedure. My other goal was for patients to find our pricing and use it. leverage a better deal in their hometown. If you, I'm flying to Oklahoma City to have this done is a real threat to a hospital in Oregon or Idaho or Wyoming that is about to price gouge someone into oblivion. And then the third goal was to better, better understand some of the scams that were a play. One thing I realized early on when I was practicing in the hospitals for seven years, I was in network with all of the big insurance carriers. When we opened the surgery center, we thought, well, we'll be a network with all these companies. We're going to be cheaper, better, more efficient. They're going to love us. And none of the insurance companies would work with us. And it wasn't really clear until later why some of that was true. When I, when I think back to fighting insurance companies like we did in the early days, and I think now about how wonderful our life is because we've just walked away. And I, and I think if all physicians would walk away and just not deal with these insurance carriers. They don't have a network if no physicians are in it. So by signing these network contracts And I don't fault anyone for signing it because there's some markets where if you're not in network with Blue Cross, you don't have a practice. But for primary care, I don't think that's true. But in our, in our case, we've been able to stay busy just accommodating the needs of those who are buying around an insurance policy, pricing procedures less than their in network deductible, so it actually makes sense for them not to use their insurance, or making ourselves known to cost sharing ministries, self funded plans et cetera. So I, I I'm very optimistic about this movement, particularly for surgical specialists going forward. I think the primary care docs have been very bold and courageous and have kind of led the way, but I think once the word gets out that you can, own, operate your own facility, make a really good living doing that, treating patients with the highest quality of care at a reasonable price and it's a little bit of a, it's a little bit of drinking from a firehose for, business wise, how do I do this? I spent a lot of time talking to physicians, educating them about that. And another point I'd make is this is not limited to outpatient surgery. There, there's another website people should check out atlasbillingcompany. com. Those are Those are inpatient prices, including maternity care that I've cobbled together through the years dealing with with area hospitals that said, yeah, we, we do want to see that patient from Florida here in Oklahoma City because we have a robot and I don't have a robot. And so that, there, this movement is growing and it's beginning to spill over into more and more complex. inpatient surgical care.

Maryal Concepcion MD: 25:14

for those people who are listening and are like, okay, I, I hear that, the, the breast mass removal was under 2, 000 for the whole thing, not just the facility fee. I think about common surgeries that my patients have gotten over the years, knee surgery. Tell us what a knee surgery looks like, especially not only just the price, but the patient experience and how the entire experience is different from the time that they need to be, evaluated by a surgeon and the surgery needs to happen as well as after the surgery happens.

Keith Smith MD: 25:47

So we we do a joint replacements on patients from all over the United States. We did a knee replacement on a patient from Alaska last week. We did a hip replacement on a patient from Canada a couple of weeks ago that that's just commonplace at our facility. But if someone has been told that they need a knee replacement and they have sticker shock, they really do, it is, it's out of their pocket directly or indirectly through their proxy employer. They'll reach out, I connect them to a surgeon, the surgeon reaches out to them directly, talks to them on the phone they arrange an exchange of information so the patient can send images and clinically relevant relevant information to the surgeon. Surgeon confirms that yes, you're a candidate for a knee replacement. And then we pick a day. and they fly to Oklahoma City usually the day before surgery. We have already talked to them on the phone to make sure there are no medical issues that need to be addressed prior to their travel. And then when they arrived, we meet with them at the surgery center the day before or two days before whenever they would like to come. Draw some basic lab. Make sure everything is exactly as it was presented to us over the phone and over any kind of telehealth visits that have happened up to that point. Then they come in the morning of surgery. We we place a pain catheter into the adductor canal so that they have local anesthetic. That's pumped and infusing into that canal for five days and have very little if no pain, very little pain. A surgeon performs the surgery and our price includes the surgeon anesthesia facility. 30 days of physical therapy at home, wherever they live, their durable medical equipment, all their pain and anti clotting drugs and home health visits while they're in town for a week. The only thing not included in our price. I think our price is about 18, 000. for all of that. The only thing not included is the implant. But we quote the implant after the surgeon has talked to the patient on the phone and reviewed the images. But those are those are fairly customized, and we don't really know 100 percent what we're going to use until until the exchange of information happens. But that price is quoted prior to surgery. So the patient knows exactly how much they're going to pay, and it's designed as what my friend Jay Kempton calls cash out the door pricing. So they know they are never going to get another bill for anything, for crutches, for a walker, for a scooter, nothing. They're never going to get another bill. They're, they're completely finished. And I'm just very, very grateful, satisfied, happy patients. That's, that's kind of what it looks like to walk through as a patient.

Maryal Concepcion MD: 28:53

it's so interesting because in the world of direct primary care, the culture is very much still, but I have good insurance. And it's yes, but, but that's what you think. But let's actually break down when you pay 0 for your medication, and then your insurance cost goes up next year. And then less doctors are in network, or you don't have access to a physician any longer. That's actually not costing you 0, even though your, your bill right in front of you is 0 for your listen or pill or whatever it is. And I think that when you talk about this out the door pricing, I think that, again, it empowers our patients. and so much because if a person is in whatever financial situation they're in, it's just like when you buy a house or when you buy a car or when you buy, you know, a piece of luggage and you know that cost, and then you save up until you know your budget fits so that you can afford it. For me, I think about the patients who are like, who are avoiding getting care because they assume that they're going to go bankrupt versus the person who says, Alright, so this is the price. Fantastic. What can I do to plan for this, it refocuses their healthcare journey on a plan, rather than despair.

Keith Smith MD: 30:07

If somebody's paying 1, 500 a month for insurance, whatever that means, and a lot of people are, that's 18, 000 a year. And, the common reply is, yeah, but what about open heart surgery? Well, open heart surgery, a three vessel, four vessel bypass in Oklahoma City at a, at a facility that a colleague of mine runs is 34, 000. So that's two years of premiums. So when you think about it that way, and, you pay 1, 500 a month just to have the opportunity to meet your 8, 000 deductible, or 10, 000 family deductible. So, yeah, when people think they have good insurance, I'm not even really sure what that means. We're self funded at Surgery Center of Oklahoma for our employees. Nothing comes out of their paycheck. I, I send a aliquot of money every month to our own self funded health plan, and I buy all of the medical care that my employees need out of operational revenue out of that plan. They don't pay for anything. They have zero deductible. If they need something done, they get it done. One of my employees husband has a patent for menovale, it turns out, and it became symptomatic recently. Then he's going to go to a cardiac lab and have that fixed and they're not going to pay anything because I've already prearranged all of the pricing and the Surgery Center of Oklahoma's plan will pay for that. So, self funding is something that your physician audience should really familiarize themselves with because understanding that and their plight and that they have the same sticker shock as an individual buyer. provides the confidence. I think a lot of surgical specialists need to walk away and just secede and no longer let United, Cigna, Aetna, Humana, and the rest of them just beat the crap out of them on a daily basis. We don't have any contracts with any of those folks and And I don't intend to.

Maryal Concepcion MD: 32:15

So when we talk about self funded, I think about the employer space because clearly employers have absolutely like smart employers have absolutely seen the value of what happens. Wow. What happens if you actually get healthcare for what it costs and not what the insurance charges you. So tell us about how employers are also acting similar to you and that you are an employer providing healthcare in a self funded manner for your employees and their, families.

Keith Smith MD: 32:42

Yeah. So, so the audience understands in 19, we opened in 97 and in 1999, I realized we were paying 20, 000 a month for 20 employees. Yeah. To have insurance. I believe at the time it was with Blue Cross. And I called an insurance friend of mine and I said, we, we are doing very well. We have good cash flow. Why can't I just buy an insurance policy for the employees that has 150, 000 deductible? Because I know I'm going to pay 240, 000 this year, paying 20, 000 times 12 months. Why can't I buy a policy? I take 150, 000 of risk and then pay premiums on top of that. And he laughed and he said, Well, that's called self funding and he said where you take more risk and and then you pay, you pay the medical bills, basically yourself. And he said, you actually don't even have to take that much risk. So we self funded in 1999 and and have been self funded ever since. Well, most companies now, I would say 50 or more employees. are self funded because they they can do precisely what you said. Save money paying for what the care costs rather than what insurance charges them for it. I love that's a great way to put it. When I launched the website in 2009 I was approached by Jay Kempton and Jay runs what's called a third party administrator. So when I say I'm self funded and I pay my employees medical costs out of operational revenue, what I mean by that is I, I do that, but I don't have the checkbook. I've given the checkbook to a third party administrator, and that's what that means. So. My third party administrator happens to be Jay Kempton, but that's what third party administrators do. They they pay the bills for their self funded clients. To make matters more confusing, there is something called an ASO, Administrative Services Only, and that is where Cigna Aetna Actually perform the task of a third party administrator, and that's really gross when they do that. Now, no one is saving any money at all, but independent third party administrators exist in the United States, and they are the friend of the surgeon specialist because the surgeon specialist watching your show right now says, you know, I can see me. How these primary care dogs can do this, a lot of patients out there will pay 90 or 100 a month, for a subscription based practice, but no one can pay for my 9, 500 cruciate ligament reconstruction or fill in the blank. Well, put yourself in the shoes of the self funded employer. They have seen a bill for 80, 000 for rotator cuff repair. They've seen bills 30, 000 for tonsillectomy. Do you think they would not like to buy a 9, 500 cruciate ligament reconstruction? They'll buy that all day long. So, the, the self funded employers in the United States make up half of all of the non Medicare, Medicaid revenue that is spent on medical services. And they're shopping. They really are looking. So, every time a surgeon boldly steps up, an endocrinologist boldly steps up, fill in the blank, and says, okay, here I am, here is what I do, here is what I charge for it. There's a demand for that. There's a real demand, a pent up demand for those services. So, yeah, we're self funded. Then all the companies we deal with that are that are self funded love us. We have contracts with self funded companies in 49 states, and those employers will pay the travel costs for the patient and a companion and waive all out of pocket. for them to come to Oklahoma City. And unfortunately, we have copycats now that and in their friends there, they're not enemies, their competitors. I don't consider my competitors enemies like hospitals do. But yeah, so there are more options now for patients in the United States than there, than there were back in 2009 when we got this started.

Maryal Concepcion MD: 37:22

you know, I think about how many, and I think this is really highlighted by the pandemic, how many people get their insurance or health insurance through their employer. And so I really think that when, there's employers out there who are still Oh, sure. Absolutely. Thank you so much for my 22 percent increase for my Buka plan. Buka meaning those companies that you mentioned, Blue Shield, Blue Cross United, et cetera, et cetera. And there's less care and more expensive bills for every care that is delivered under those plans. Employers. Who may not know of just like you did, you weren't necessarily aware that there is a term called self funded plan out there. I hope that this also educates them when it comes to the physicians. When it comes to the physicians, the surgical specialists who are like, Yeah, there is no way because I totally, because I've heard it so many times. Yeah, the primary care doctors can do that, but I'm a surgeon and clearly you have a very, a large and thriving surgery center. Like you mentioned, there's other cash pay surgery centers open in the United States. Patients are coming. Patients need this care. They need this option. You mentioned how you speak to people and you speak to fellow physicians and you, you talk to them about, ways that they can transition conveniently in April, coming up April 9th to 11th in Oklahoma city, Oklahoma there is going to be the 2025 free market medical association conference. So tell us about. The, tell us about that and, what could a surgeon who's, who's leaning in listening, who has looked into this, but isn't still really sure as to what to do what can a person who is a surgical specialist or even a primary care doctor glean from coming to the FMMA conference?

Keith Smith MD: 39:11

Well, the answer to that is probably best answered by talking about where this organization came from. when I posted prices online and Jay Kempton and his clients found me they started directing business my way away from other facilities in Oklahoma because of the just ridiculous price difference. Well, you can imagine that didn't make many friends for me the people who were losing the business. And so they were yelling at Jay. Wanting to know what are you doing taking these cases away from us and Jay said, well, just tell me how much you want so they didn't many of them did not know how to place a price on a service provided and, fair, to be fair, there are components to cobbling together a bundle price that maybe are not intuitive. So I helped. My competitors come to terms with how do you put a price on what you do. In the meantime, Jay's competitors were wanting to know how are you dealing with these mavericks who, who are just sending you an invoice and getting paid. No Hickville Forums, nothing. I sent an invoice, it's one page, and that's my, that's how I get paid. And so Jay taught his competitors. How to deal with a facility like mine and at one point Jay said, this is becoming a little bit of a movement. I wonder if we ought to start an association if for no other reason so that we can all get together and convince each other that we're not all insane. And, and so that's how the Free Market Medical Association started. And it's grown now. It's a large organization with 37, I think 37 state chapters now. We've had keynote speakers that everyone knows Lisa, Lisa Kennedy from Fox Ron Paul Steve Forbes just very well known keynote speakers and fans of this movement. And so this year our, our theme is monopoly. How, how you come to grips with the rules, that, that are fixed, that, in the system, you really can't do anything about and then, and then how do you understand how to really just walk away from the monopoly game? A surgeon or a specialist that attends the meeting will meet others that are in various stages of development intellectually and realistically, are they, are they attempting to purchase a facility? Are they part of the facility that's considering mending their ways and putting their toe in the water and attempting to accommodate? Sticker shocked patients and employers so that they don't continue to lose business to people like me. So people people that attend are in all phases of sort of a grief Pattern, they they're not sure if they believe it or if they're angry or sad or they've accepted it They don't really know a hundred percent where they are. Some of them do Some are part of a physician owned facility that wants to jump into this movement for the right reason So it's a real eclectic crowd but anyone Anyone that shows up will find someone that is probably at their stage of development and scratching their head, asking the very same questions. And then now, there's five or six hundred people in attendance. There are people, I'm not the only one, there are a lot of people there that can help. Give the confidence to ask the right questions. Make sure people are thinking through embracing these ideas in a correct and in a safe, not a reckless way. We don't recommend that anyone just cast their practice on the rocks, with some daring bold move. There are people out there that have done that. So, it's a, it's a great meeting. Everyone leaves very, very inspired. Typically to take the next step

Maryal Concepcion MD: 43:33

and, being in that in that crowd that we know was full of, of grief. And I love the way that you put that because you, you have so many feelings when as a physician, you're, you're angry at so many things, you're disappointed by so many things, you're hopeless about so many things when, you're, Reimbursement goes down when your patient numbers go up when your patient visits per day or per hour increase when you are not even able to, be present at home because you're so strung out and burned out by, playing the game of I have to get my charts done within 72 hours. I think that this is, it's so important for people to be in a room with a like minded or like minded. Curious individuals, because I think that sometimes you don't even know what you need to hear to start going on to the next step. And, where, where you spoke about how you, like, how the creation of Surgery Center of Oklahoma was just very clear. I think it, it is so helpful for people to be in a place where there's already people, like you said, there's People of all stages, but there are already people like yourself who have done it because they think the journey becomes less scary. I definitely will say that's what's happened in the, in the direct primary care movement with more people joining. It, it isn't, it isn't such a Oh, but I could never do that. I don't have an MBA. And it actually becomes something that, it, it, it becomes empowering. It becomes empowering to be around other people to say. You are a doctor. You went to doctor school. You can do a lot of things, including step away from insurance because you're not getting valued the way that you should be for your service and the things that you're able to do for your fellow community member.

Keith Smith MD: 45:21

One of the most, one of the most empowering and inspiring parts of the conference is when you see a surgeon or a specialist encounter. a self funded buyer who says, where are you located? Are you kidding me? And the next thing there is a buyer seller relationship that has happened. And those kind of hookups happened at the surgery at the free market medical association every year. So, it, it's very inspiring. And for any specialist that is contemplating going down this road, And that's that's a great meeting to attend and also a great place to meet the people who want to buy what you are selling.

Maryal Concepcion MD: 46:05

So this is where I will say if you are inspired, if you are a surgeon, if you know a surgeon, if you want a surgeon who is able to do cash based pricing listeners to the podcast can get an exclusive 800 off of their registration for the annual conference put on by the FMMA coming up April 9th to 11th, in Oklahoma city, Oklahoma to get your 800 off registration, use the code my DPC story. That's M Y D P C S T O R Y, one word, and make sure that you register because Dr. Smith said, Hundreds of people go to this conference and this is growing every single year. So, to get your hotel reservations and your car reservations, et cetera. we're almost to April. So I definitely would say get on the internet. Go to FMMA. org and that's where you'll find registration links. And again, there will be a blog accompanying this podcast. So definitely check that out. Because that's where you can find not only the registration link, but also the Surgery Center of Oklahoma link. Dr. Smith and I are going to continue the conversation. And really talk about, first steps that a surgeon can think about in preparation for going to the FMMA conference or for people who are interested in, pursuing this sometime in the future. Strategies like how to look at your contracts now so that you're not excluded from doing something like this. But for now, thank you so much, Dr. Smith, for sharing what you are doing at the Surgery Center of Oklahoma.

Keith Smith MD: 47:33

Thank you. Thanks for having me.

Maryal Concepcion MD: 47:38

That's a wrap for this episode of My DPC Story. Thanks so much for tuning in. If you've enjoyed the show, please take a moment to leave a five star review on your favorite podcast platform. It really helps others discover the podcast. Got a burning question about direct primary care? Leave us a voicemail and stay tuned. You might just hear it answered by a future guest. Follow us on your social media platforms at our handle, at My DPC Story, and join us for DPC Didactics, a monthly virtual space where you can join me as we dive deeper, answer questions, and troubleshoot challenges. Challenges together. Find the link@mydpcstory.com. For exclusive content and behind the scenes access, look for my DPC story on patreon.com and for DPC News on the Daily. Be sure to check out DPC news.com. Until next week, this is Marielle conception.