No. 003 · Sunday
THE MEMO
I stopped checking what was covered
For years, before I walked into a room, I had already narrowed what I was going to
recommend. Not consciously. I would look at the condition and somewhere in the back of my
head I was filtering for what insurance would pay for.
Almost every doctor I know does this. Nobody teaches it. You just absorb it.
Then I changed one thing. I stopped looking it up first.
Now I list everything I could do for this patient's condition. All of it. Then I ask myself
one question: if this were my mother, my uncle, my daughter, my son, what would I actually
provide?
That's the whole shift. I don't decide what to recommend based on who's paying. I decide
based on what would fix the problem, and then we talk about how to pay for it.
What it cost. Real money, and it stung. Some patients heard a cash price and walked, and
early on every one of those hurt. My own staff pushed back, because it wasn't how we had ever
done it, and a couple of partners thought I was making a mistake. Revenue dipped while the new
way found its footing. None of it was free. I just decided the old ceiling cost more.
What it returned. My close rate went from about three in ten to six in ten. My average
revenue per visit went from $120 to $250. Both inside thirty days.
Sit with that $120 for a second, because it's the real lesson. That is what a visit is worth
when you only ever recommend what's covered. It isn't a pricing problem. It's a
recommendation problem. The ceiling on a visit gets set by what you're willing to put on the
table, and mine was being set by an insurance card I had already read.
I didn't double that number by raising a price. I doubled it by raising what I was willing
to say out loud.
And if revenue per visit is fixed, volume is the only lever you have left. More patients,
longer days, more staff, more overhead. That's the treadmill, and it's why so many good
doctors are exhausted and still not earning what the work is worth.
Notice what I didn't do. I didn't add a service. I didn't raise a fee. I didn't drop a plan.
I changed the order of operations in my own head.
You can do this Monday morning. It costs nothing and nobody has to approve it.
TJ
THE SIGNAL
Three things worth your attention this week.
Ambient AI scribes are finally posting hard numbers. A large JAMA study across five
academic centers found they cut documentation time by about 16 minutes per encounter, and
Mass General Brigham reported a 21.2% drop in clinician burnout after 84 days of
use. The value is showing up as measured minutes now, not vendor promises.
The average ACA Marketplace deductible jumped 37% in a single year, from $2,759 to
$3,786, the steepest rise in the program's history, as enhanced tax credits expired.
A KFF analysis found bronze-plan sign-ups climbed from 30% to 40% of the market.
More of your patients are paying full freight long before insurance does anything.
About 10% of US primary care physicians now offer direct primary care, per
the American Academy of Family Physicians, and the cash-pay model is spreading to
specialists. Insurance-first medicine is no longer the only door, and patients are the ones
pushing it open.
WHERE I’LL BE
MIS Intensive Private Cadaver Lab
September 25-26, 2026 · Glenview, IL · CME Dynamics HQ
misintensivelab.com
Syndicate Mastermind, In Person
October 23-24, 2026 · Glenview, IL
privatepracticeaiworkshop.com
