The Invisible Hand Challenge, MD Style

invisiblehandDoctors give advice for a living.  It’s often pretty good advice, especially when it comes to what treatments will make you feel better or what lifestyle choices will make you feel worse.  When they venture beyond that important, but narrow, field their advice often makes you wonder if they live in the same reality their patients occupy.

As evidence, I introduce this hoary bit of Randian, free market, invisible-hand-of-the-marketplace advice for fixing healthcare that I’ve seen at least five times in the last week from people who are not fools.

Screen Shot 2018-05-30 at 11.17.23 AM

Do you see item #1 on that list?  How much will this cost?  Well good fucking luck getting any sort of meaningful answer to that question in any healthcare setting from primary care to ICU in any part of the United States.  Seriously, who writes this shit?

An Anecdote to Set the Scene

Not long ago, I was being held hostage in a very shitty insurance plan and wanted to minimize my interactions with the plan as well as my out-of-pocket.  So I made the mistake of asking my rheumatologist what the bone density scan he was recommending would cost.

If I had concussed him with a two-by-four he could not have looked more stunned.  Eventually he recovered, looked around and got the attention of his nurse and asked her to find this information for me.  I wish I’d gotten a picture of her face, but fortunately I can read minds and here’s a transcript of what she was thinking as she stared dumbfounded at the two of us:

Here are two visitors to my planet who do not know how things work here.  Fortunately, they both have miniscule short-term memory and neither one actually expects an answer, so … having wasted several hundred milliseconds thinking about this, I will now respectfully shitcan that unreasonable request and move on to tasks for which I am actually trained and capable of accomplishing.

Suffice to say, that number was never provided, but I had my revenge … I never went for the bone density scan.  Win/win!!

The Challenge

In an effort to make sure that I never hear this awful advice ever again from people I otherwise respect, here’s a challenge for all the “ask what it costs” MDs:

  1. Tell every one of your next 10 patients what your treatment (office visit, tests, procedures, scrips …) will cost THAT patient.  For 10 people, at worst you’ll have to figure out a couple of dozen numbers.  There’s a few rules:
    • You have to find it out yourself, not dish the task to your office manager or nurse as my rheumatologist did.  This a learning experience for YOU and the best learning is direct learning.
    • The answer you give them has to be an actual number, not an algorithm, range or a percentage.  Asking a sick person to solve a multi-variable equation where most of the variables are not discoverable does no one any good.
    • You have to give them the number while they are still in your office.  Remember, we ignorant patients are using this number to make a decision about treatment options and need close consultation with our physician to get it right.  If you send us away without this number you’re just driving us into the arms of Doctor Google.
    • Here’s a tip to get you started – remember to ask if they’ve met their deductible for the year.  Good luck!
  2. A month later followup to find out what it actually cost THAT patient.


You get one score per patient.

  • 20 points for a direct hit defined as getting the total number for that patient’s recommended course of action within plus or minus 20%.
  • -10 points for guessing high by more than 20%.  Remember, some number of people will forego treatment based on price.
  • -50 points for not finding a number you’re comfortable with.
  • -200 points for guessing low by more than 20%.  Remember, most of your patients can’t absorb an unexpected expense greater than $400.

So in this challenge your score as a believer in the invisible hand of the marketplace will range from +200 to -2000.  Why are the negative scores so much higher than the single positive? You’re a believer that a) the price is knowable and b) that patients MUST demand to know it in order to fix our fucked up healthcare system.  From a patient perspective you, the doctor, should get ZERO points for knowing the price of what you’re selling.  Beyond that, healthcare is different.  Success is status-quo-ante, failure is pain, bankruptcy and death.  Deal with it.

If your total score is less than zero, your invisible-hand-of-the-market ask-what-it-costs advice is bullshit and you have to stop saying it.

My Prediction

No one will admit taking up this challenge.  Those that poke around it will find quickly that the the money that changes hands in any particular US retail healthcare transaction is not any more knowable than the current state of Schrodinger’s Cat.

Post your results in the comments.


About JR
Software guy, startup guy, non-fiction glutton, south shore inhabitant

One Response to The Invisible Hand Challenge, MD Style

  1. Heather Clark says:

    Thank you. Now please arrange to publish this in every major media outlet until they finally agree to stop repeating this flat Earth theory of medical system reform.

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