Price, Value & Grace

One of my areas of professional expertise is infertility surgery, specifically reversal of vasectomy. Vasectomy is a very common form of permanent birth control, with an estimated 500,000 to 700,00 procedures performed a year in the U.S. It is a procedure which is devilishly simple to perform, while maddeningly difficult to repair. The vas deferens is a small, thick-walled muscular tube (2.5 mm = 1/10 of an inch in diameter) which transports sperm from the testes to the prostate and seminal vesicals. Its division to achieve sterility is a simple office procedure — but the extremely small diameter of its central channel (0.2 mm), and the tendency to form secondary obstructions after vasectomy in an extremely delicate structure called the epididymis, make successful restoration a daunting challenge, requiring that the repair of the duct system reliably be performed under high magnification, using a technique called microsurgery.

While increasing number of urologists are trained to do this specialized surgery, consistently successful outcomes require many hundreds of cases and many years of experience, a factor which few recently-trained urologists bring to the table. I have had the good fortune to have this kind of experience, going back nearly 30 years, and as a result have one of the largest experiences in this procedure in the country, and have performed reversal surgery on patients from all over the U.S. and a number of foreign countries.

Reversal of vasectomy is rarely covered by health insurance, and the procedure is expensive: costing $15-20,000 and up in some large referral centers. I have over the years, built and sustained a large surgical experience by pricing my services well below much of the competition, creating a win-win situation: higher volume (and therefore greater experience and surgical expertise) while providing a substantial cost benefit to my patients.

But the procedure is still very expensive. Too expensive for many.

I receive quite a few e-mails from my web site, most requesting additional information or expressing an interest in scheduling surgery.

So yesterday’s e-mail came as a bit of a jolt:

I am highly disappointed with the fact that your coding on the web implies that your procedure is affordable, do you honestly believe that your fees for this procedure are affordable to anyone desperately wishing to have a child. I am not sure which world you live in — it is not mine.

How much more pain must men suffer for making a mistake; how much more must a man suffer to regain the blessing of GOD to have a child.

My mouse hovered over the Delete button momentarily, atypically restrained. After all, complaining about rich, greedy doctors exploiting the poor is something of a hot-button issue for me, and I waste little time arguing with those so convicted, preferring to leave them to their personal anti-physician jihad.

But this one seemed different. After a few moments, I managed to swallow my annoyance (with a chaser of pride), and at least leave the e-mail untouched. Soon, I realized it was important to reply.

Here’s what I wrote in return:

Dear Bill [not his real name],

I greatly appreciate your note, and understand well your frustration at the high cost of reversal surgery. To you these fees seem unreasonably high, an insurmountable barrier to the deepest need and desire of your heart.

By any objective standard, my fees for this procedure are reasonable. My current expertise in this area has been acquired through a long and arduous education and training experience, augmented by nearly 30 years of experience in performing this microsurgical procedure, which is extremely demanding — perhaps one of the most difficult procedures in all of surgery, regardless of specialty. There are perhaps no more than a few dozen surgeons in the world who bring this kind of experience to the restoration of fertility after vasectomy — yet many surgeons with far less experience, using cruder and often unsuccessful surgical techniques, are charging as much or more than this for the procedure. Top specialists in this field — which you know if you have researched these costs — not uncommonly charge two, three, sometimes four or more times as much as the fees I have quoted. Do I believe that many of these charge far too much? Most definitely — but most have earned that right through rigorous training, long hours, and hard work. They most certainly have the right to charge what they will — as you have the right to have this procedure, or not.

So I make no apologies for my fees. You say I do not live in your world, which is most certainly true; you also do not live in mine. Could you sustain the $40,000 a month which it costs to keep the doors of my small, efficient, one-doctor practice open? Do you believe these fees go merely to line my pockets, to keep me in Porsches and luxury yachts? Believe what you will, of course — but as the apostle Paul says in 1st Timothy (5:18), “The laborer deserves his wages.” The God who judges you also judges me — and before Him I am confident that these fees are just and not extortionary.

But they are, clearly, far more than you can afford — and thus serve to condemn you to a mistake you are convinced you have made. I, too, have made costly mistakes in life — mistakes which not only cost large sums of money, but squandered the far greater treasure of the trust and respect of those I love, and undermined and nearly destroyed a faith in God many years in the building. That same God reached out in immeasurable grace to me, condemned as I was, and restored me in ways unimaginable to me, then and now.

So here is my offer to you: I will perform your reversal surgery at no cost to you. There will be, of course, fees for the hospital and anesthesia which I cannot reduce, as they are not under my control. Their fees as they stand have very little profit margin, and cover little more than their expenses; I have worked with them for many years to keep these costs as low as feasible.

Let me know what you think.

And above all, begin to know something of a God who values grace and mercy more than sacrifice.

Oscar Wilde once described a cynic as a man who knew the price of everything and the value of nothing. Wilde, himself a witty but cynical agnostic, nevertheless had some glimpse of true wisdom here. Sometimes the greatest value comes from that which costs nothing, yet which no amount of money can buy.

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20 thoughts on “Price, Value & Grace

  1. That is what I call magnanimous. I would not call getting a vasectomy a “mistake.” Your offer is way generous. Please let us know if and how he responds.

  2. Wow . . . I looked at your prices and they are cheap (comparitively)!

    It would be nice if more doctors could be/would be more straightforward about service pricing. Of course in part this goes back to the whole medical billing mess . . .

  3. Grumps,

    Good question — I did have a moment’s hesitation about putting out on the blog. I felt the principle trumped the risk. Nothing like offering free services to boost volume … but a bad business model, generally. My accountant would not approve.

    This sort of offer is rather extraordinary (I’ve done it a few times before, under different circumstances). But in every case it was something I initiated, rather than something the patient asked for.

    So if you’re out there thinking, “Wow! Free reversal surgery!” — think, David Spade: “No!”

  4. Hoots,

    I have a fair amount of ambivalence about vasectomy, actually — I do not entirely agree with the Catholic (and some fundamentalist Protestant) position that BC/sterilization is inherently wrong. But I do think it is done far too lightly, and is, at least at times, a manifestation of our self-centered lifestyle (“No more kids, because we need more money for a grander house and a new boat.”)

    Nevertheless, my e-mailer felt for him it was a moral error which felt a strong need to correct, and I respect that position.

  5. Ah, yes, the vasectomy as an emblem of the self-centered lifestyle. It is, many times, an all too correct assessment of the procedure. I’ve seen it and written about it and the attempt, decades ago, to reverse it.

    This great essay makes me think it is time to bring it back.

  6. Your blogs never cease to speak to me of God’s grace and how it changes lives. I hope that the man who wrote to you read very carefully your response and, in particular, your last statement to him.

  7. Dr. Bob, your reply to the fellow does not surprise me – at all. What I’ve come to know of you makes me realize that I would have been more surprised had you handled it differently.

    Thank you for sharing yourself with us. You’re truly a “physician” in more than one sense of the word.

  8. I suspect that man is so surprised by your reply that he cannot close his mouth. You are storing up treasures in Heaven, Dr. Bob.

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