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.


Healthcare Stinks: The Revenge of the Shrimp

shrimpSo I have this condition called gout.  It’s manageable, as anyone can tell you, if you behave within very reasonable dietary guidelines.  These very reasonable dietary guidelines include avoiding things like organ meat like liver and brains, which is pretty easy, broccoli (seriously?) and beer (forget it).

There’s also an unwritten, but very real, rule of living with gout which goes something like “don’t poke the beast”.  In other words, because gout multiplies any inflammatory issue you might have, don’t do anything like “getting out of bed” that might inflame the joints.

So I start this new job, and as part of the initiation we go off to do a week in the woods team building.  Really not my thing, and I’m paying very close attention to “not poking the beast”.  By dinner time on the last night I’m feeling pretty good.  I haven’t gotten fired yet, my team (GO PLOWS!) isn’t in last place, and the beast snores contentedly.  And that’s where it all goes to shit.

They feed us a huge dinner at the restaurant on the top of the mountain where the views look like this:


Yes.  That really is the view.  We stomped all over the mountain all day and I’m beat and hungry.  There’s a fabulous shrimp thing on offer.  Garlic and oil.  I can’t get enough, and go back for thirds.

PANO_20170510_175311In case you haven’t guessed by now, those very reasonable dietary guidelines include “don’t eat shrimp”.  Within 24 hours my left big toe is bright red, swollen and ON FIRE.  With every heartbeat the toe throbs as if I was hitting it with a hammer.  And of course it’s my own damned fault.

Oh well, accidents happen.  I knew the shellfish restriction but because I seldom run into a situation where shellfish is the best thing on offer I totally forgot about it.  Like I said, it happens.

The usual treatment for this is to hit it with a decent dose of prednisone (steroid), slap ice on it, keep it off the ground for a week or so and once again, you’re good to go.  Sadly, rest is not an option.  In fact, this job seems, in a relentlessly upbeat way, to be determined to kill me before I even figure out where the mens room is.

First, there’s the walking tour of the campus, sprawled scenically over a quarter of a mile of low-rise brick buildings.  My cube is, of course, as far from the garage as you can get without being off-campus.  And being a big company, the first few weeks is an endless march from one meeting room to another.  While this is a laid-back place, full of dogs and such, I just can’t imagine that putting my foot up on the conference table with an ice bag on it will be well-received.  So I sneak in ice-breaks between meetings and continue to poke the beast.

And after one day in the office, we have to fly to Austin for a week of walking around.  Like I said, they’re trying to kill me.

So of course the toe doesn’t get better as fast as it usually does.  In fact, after a couple of weeks, when we’re winding down the prednisone, the toe’s only a little better but because I’m continuing to poke the beast by walking like a duck all day both knees and the other big toe are starting to get involved.  It’s clear that the usual script isn’t going to work here.

<Skip long sad story about communication and scheduling misfires within the office of my regular rheumatologist>

<Skip shorter, equally sad story about communication and scheduling misfires between my regular rheumatologist and the covering rheumatologist>

<Skip even shorter, equally sad story about communication and scheduling misfires within the office of the covering rheumatologist>

So we’re a month out from the start of this attack and it’s not fixed because I didn’t rest it enough, and I’m finally in to see a rheumatologist.  She takes a history, takes a look at the right toe where the attack has now moved and proposes a two-prong strategy: lots more prednisone (which I agree with) and potentially some colchicine but only if a blood test shows good liver/kidney function.  Cool.

It’s noon time on a Friday.  As she puts in the lab order I ask innocently,

ME: Is that gonna get done in time to write the colchicine scrip today?

HER: Oh sure, I’ll write STAT on it and we’ll have the results by the end of the day today.

Somehow, I am not reassured.  But I limp gamely across the hallway to the lab, literally 20 feet away.  The order is right there and they’re waiting for me.  What service!  The guy looks at my order and has only one question for me:

HIM: Are you getting imaging done?

ME: Huh? No.

But my spidey-senses are tingling.  This can’t simply be an idle inquiry from a nosey phlebotomist.

ME: But it says STAT there right?  That means it’s going to be done right away, right?

HIM: Oh yeah, it says STAT right here.

As I leave the lab my spidey-sense has not calmed down one bit, so I ask one more time:

ME: STAT, right?

HIM: Right

Suffice to say, one should always, always, always trust ones spidey-sense.  STAT written in that field, on that form, does not mean shit because the tests weren’t run by end of day, no results for my rheumatologist and thus no colchicine for me.  The fact that I wasn’t “going for imaging” put my sample in the “whenever” bin, STAT be damned.

So to put this in perspective, the strategy to kill off this gout attack that my rheumatologist cooked up wasn’t executed because two offices on the same Epic installation and located physically within 20 feet of each other couldn’t communicate the fact that this test needed to be run TODAY rather than next business day (i.e. three calendar days).

Even if the colchicine scrip is written on Monday, because of the way the prednisone scrip is written, it’ll be paired with 30mg of prednisone, rather than the 50mg it would have been paired with on Friday.  A tragedy? No.  Less effective?  Probably.  Completely unacceptable?  You bet.

What does all this say about anything?  Even in situations where providers and staff are on the same system, nay even within the same physical office, working as a team the most expensive health care in the world delivers a quality of service that would be unacceptable from a dry-cleaner or an auto mechanic.  I work with teams for a living, and if two of them dropped the ball like this, there would be consequences.  By contrast, I suspect that by the metrics Atrius Health collects, this episode will count as a huge success.

This slipup with the lab and rheumatology was only the last in a series of unpleasant interactions with the system (see skipped episodes above) that all illustrate the same point – providers within the same office, or across offices in the same EMR, are unable or unwilling to communicate such that what’s best for the patient actually happens.  Which proves, as much as anything can, that’s what’s best for Harvard Vanguard/Atrius Health and what’s best for the patient are not the same thing.

Full disclosure: All this sadness takes place within Harvard Vanguard/Atrius Health and Epic.  I now work for AthenaHealth.  That said, I can’t say this wouldn’t happen at an AthenaNet provider.

Why US Healthcare Sucks – part 1 of 243

I am preaching to the choir today so if you think any of the following list of things, fuck off and go read someone else’s blog.

  • The US has the greatest healthcare system on earth
  • If you don’t like it here, move to Canada

Early one Thursday morning, my family and I were visited by a bat.  We were all asleep in relatively close proximity, and thus were all exposed to the cute little critter for a good little while before someone had the consciousness, and good sense, to scream about it.  Good times.

dragonNow, I’ve had experience dispatching bats, and this one was no more difficult than the last.  In fact, I used an aquarium net to knock him down (and out), scoop him up and toss him out on the lawn for the neighborhood cats to deal with.   At left is an artist’s rendition of the foul beast in flight shortly before I smote him.


I immediately got on the trusty iPad to figure out what to do about the damned bats, this being #3 in the last couple of years.  In the course of my investigation, I was shocked (shocked I tells ya) to discover that, by Department of Public Health standards, I either needed to find and autopsy the bat, or we all needed to get rabies shots.  Because we were in the room.  With the bat.  While we were sleeping.  Here’s a link.  I didn’t believe it either.  But that isn’t the sucky part of our healthcare system, not by a long shot.

Annoyed but not alarmed, I searched the lawn in vain for my vanquished foe.  Alas, he was nowhere to be found.  I like to think that Nigel, the cat next door, got him because I don’t like Nigel either and that would be a two-fer. The family all slept for another hour, went out to see the Perseid meteor shower, then slept again.  The bat was unavailable for testing, and we would deal with it in the morning.

At this point, I have a family of four and we all needed rabies shots (according to DPH criteria) because we were all exposed.  And they needed to start before 1am Friday.  24 hours from exposure.

Here’s where the US healthcare system starts to shine its peculiar menacing glow.  My wife works for a hospital that self-insures.  That should have made this easy.  Instead, a voyage of discovery within her employers and her PCP’s labrynthine systems produced the advice that the entire family should go to the emergency room.  Not only that, but we should call ahead to make an appointment.  The irony of making an appointment at the Emergency Room did not make anyone laugh.  The irony of paying 4X an emergency room charge ($100 each) rather than the 20$ copay for an urgent care visit did not make me laugh either.  This was clearly not yet an emergency as any normal person would define the word.

But as any procrastinator knows, you can turn anything into an emergency if you wait long enough, and by early afternoon my wife (who has a job above and beyond finding out where to get rabies shots) was stuck with the emergency room as our only option.  We had about 12 hours to start the series, and about 4 hours before the healthcare system in general stopped answering the phone.  This was clearly not an emergency, but if it could stiff-arm us for another 4 hours the healthcare system would turn it into one.  My resolve not to contribute to the rampant abuse of emergency room care was wobbling.

receptionistSo off to MY PCP I went.  My PCP works in a big, nice, multiple-group practice.  I like the building, which has nice bathrooms, and many of the people within who sometimes help me feel better when I get sick.  That said, interacting with my PCP’s office is an act of desperation because they have always been dreadful to deal with.  They did not disappoint.  The moron who screens calls there seemed unable to comprehend that, at 3pm I didn’t have the luxury of setting up an appointment only for myself, and only to “talk about it”, when the entire family was exposed at 1am that day.  You have 24 hours to start the rabies series.  If I had to make “talk about it” appointments at 3 different PCPs we’d end up in the emergency room anyway.  I had other people relying on me to take care of them and this moron was simply unable to comprehend this, or more likely did not have the authority to do anything but repeat over and over again “do you want an appointment for yourself or not?”.  She does however have the authority to tell me she doesn’t like my attitude. She puts me, so she claims, in the queue for a callback.

Now I know that answering calls at a doctor’s office is not a fun job.  I know that talking to me is not always a fun job. I know that the men who profit wildly from the existing system (administrators, payers, doctors) hide behind the women who don’t (nurses, receptionists, assistants).  I know that the people I talk to on the phone do and say only what their tightly proscribed role allows because they need a job and, in an at-will state like Massachusetts, can be fired for no reason at all.  I know all that.

Still, the overwhelming impression one gets from working with my PCP’s office is that they really don’t like people who … need a doctor.  That the organization itself exists for some other reason than, for example, to give rabies shots to people who need them.  I struggle to imagine what that reason might be, yet there it is.

I received my callback from the PCP 5 days later at which point, had I waited for it, I would already have rabies.  I suspect that might have been okay with my PCP’s receptionist – after all, people with bad attitudes deserve to get rabies.  In any case, that fool, and that foolish system would have put four people in the emergency room when their PCP, Harvard Vanguard Braintree was perfectly well equipped to handle the issue in a timely fashion.

That’s why the US Healthcare System sucks.