Introduction: Paging Humanity - STAT.
There was a time — not that long ago — when becoming a doctor was considered the pinnacle of human achievement. A sacred calling. A sure path to prestige, prosperity, and purpose. Parents dreamed of it. Grandparents bragged about it. Society revered it.
Today? That same profession is hemorrhaging talent. Family doctors are ghosts. Pediatricians are unicorns. Internists are chained to EMRs like Dickensian clerks, clicking through pop-up reminders instead of listening to beating hearts. And if you’re lucky enough to find a physician accepting patients, brace yourself: You’ll be seen in six months by a third-year resident or a nurse practitioner armed with a laminated decision tree.
This is not an exaggeration. It’s not burnout. It’s not even late-stage capitalism. It’s a slow-motion detonation of the physician’s role in American life — the deliberate commodification of care, stripped of its humanity and optimized for spreadsheets.
We’ve taken the most educated professionals in our economy and reduced them to hamster-wheel workers with quotas called “RVUs,” forced to chart obsessively, bill defensively, and endure silently while administrators, insurance companies, and medical-industrial conglomerates squeeze every drop of clinical dignity from the system.
It’s why medical students are fleeing primary care. It’s why seasoned doctors are walking away mid-career. It’s why the phrase “my doctor” now feels like a luxury from a bygone era.
And in a country that spends more per capita on healthcare than any other in the world, the irony is almost surgical: the people we depend on to save our lives have lost the ability to save their own professions.
Chapter I: From White Coats to White Flags
If you want to understand what’s gone wrong in American healthcare, start in the exam room. No, not the one with the patient. The other one — the tiny office in the back hallway, where a doctor sits alone at 9:47 p.m., dictating the last of 28 patient notes while ignoring their own migraine and a blinking reminder about incomplete billing modifiers.
This is what medicine looks like in 2025.
In the 1990s, doctors still believed they were the architects of their careers. They built practices. They had autonomy. They chose their patients, their hours, and — to some extent — their incomes. Hospitals and private equity firms hadn’t yet consolidated half the map. Health insurers hadn’t yet perfected the art of denying care with clinical-sounding opacity. And if you said “RVU” out loud, you’d get a confused look, not a panic attack.
Fast forward to today: autonomy is a memory, and control is a myth. Most doctors are now employed — not empowered — by massive health systems that treat them like mid-level managers with stethoscopes. They’re judged not by patient outcomes or professional judgment, but by how many “encounters” they can log in a day and whether they clicked the right box in Epic.
The new doctor dream goes something like this:
🎓 Graduate with $275,000 in student debt
⏳ Spend 7–10 years in training
📉 Accept a salary lower than your radiology tech (with better hours and less liability)
🔁 Hit RVU targets or kiss your bonus goodbye
🖱 Click 1,100 times a day in your EMR
🧾 Fight with coders over a Level 4 vs. Level 5 visit
📦 Burn out by 42
🧘♂️ Become a yoga instructor, or better yet, a consultant
And yet, we still expect them to perform miracles. We expect emotional availability, encyclopedic recall, and uninterrupted presence — all while documenting 22 bullet points, selecting 3 diagnoses, assigning ICD-10 codes, and somehow clicking “wrap up visit” before the next overbooked patient barges in late, angry, and sick.
The worst part? This wasn’t an accident. It was a business plan.
Hospitals, insurers, and venture-backed “care delivery platforms” discovered that medicine, properly disassembled, could be a gold mine. You just had to de-skill the labor. Strip the narrative. Control the input. And create a physician workforce that behaves like a content moderation team in Bangalore — highly trained, highly replaceable, and too tired to fight back.
But the numbers didn’t lie. Once you replace the house call with the call center, the seasoned doc with a digital triage flowchart, and the 60-minute visit with a 12-minute coded episode, you don’t just save money. You make it. By the billions.
The physicians saw it happening in real-time. They watched their notes become audit traps. Their relationships with patients became throughput metrics. Their compensation became an actuarial puzzle tied to denial rates, billing accuracy, and pre-auth compliance.
And yet, they kept showing up. They still do. Because medicine — for all its indignities — remains a calling. One that’s slowly breaking the people who answered it.
Chapter II: Code Dirty to Me - How Billing Broke the Back of Medicine
In medicine, there’s only one language more confusing than Latin and more dangerous than bad handwriting: billing codes.
Before you worry about hitting RVU targets, you’ve got to get paid in the first place — and that means picking the right code out of more than 75,000 choices in the ICD-10 catalog. And if you pick the wrong one? No payment. Or worse: a fraud investigation.
This is the purgatory where American physicians now live — a no-man’s-land between clinical care and bureaucratic comedy, where survival depends not on your medical knowledge, but on your ability to document a routine ear infection like it’s a Pulitzer-winning novella.
It’s not healing. It’s tactical fiction.
How Absurd Is It? - Glad You Asked.
Behold, actual, no-joke ICD-10 codes used in the wild:
And yes, these are all different from W00.0XXA, which is falling on the same level involving ice and snow, and that’s different from falling on different levels, or falling while dancing, or falling during yoga. (There's no code yet for “falling into despair while charting,” but give them time.)
The Physician’s Coding Gauntlet
Physicians now spend hours after clinic carefully choosing whether that headache was chronic, episodic, intractable, without aura, unspecified, or simply caused by coding itself.
Code it too simply? Denied. Too aggressively? Audited. Code it perfectly? Still denied — because you forgot to include the Z-code for “feeling seen while coughing.”
Want to bill a moderate visit for a diabetic with kidney issues and hypertension? You’d better include five different ICD codes, document your thought process, list all medications, check boxes for “counseling provided,” “lab results reviewed,” “interdisciplinary discussion considered,” and — ideally — include a short haiku describing your emotional connection to their A1C level.
And even then? You still might get this back from the insurer:
“Claim denied. Reason: Diagnosis and procedure mismatch. Also, the moon was in retrograde.”
The Modifier Matrix
But wait — there’s more!
Enter the modifiers. These are tiny two-digit codes tacked onto CPT codes that can mean the difference between $50 and $500 in reimbursement.
Some greatest hits:
Gaming the System, or Just Surviving It?
The dirty secret? Doctors are coached to code “smarter.”
Hospitals, billing departments, and third-party coders regularly coach clinicians on how to “optimize documentation.” That’s code for: inflate the complexity just enough to dodge accusations of fraud while still getting paid like a medium-sized derm practice.
You don’t just treat hypertension anymore. You treat severe essential hypertension, uncontrolled, with comorbidities. You don’t just manage diabetes — you bill for diabetes with ophthalmic manifestations, neuropathy, chronic kidney disease, and foot ulcer — type 2, poorly controlled. That one’s worth a few hundred dollars more. And your RVUs thank you.
Is it honest? Maybe. Is it sustainable? Absolutely not. Is it the only way to survive in a system where routine care reimburses like a lemonade stand and advanced care gets denied for missing an asterisk?
Yes.
Medicare, Medicaid, and the Never-Ending Shave
Medicare might pay you $82 for a complex 30-minute consult. Medicaid might pay you $48 for the same. Then your claim gets “adjusted” (read: shaved) by the insurance carrier. Then they bundle services. Then they delay payment. Then they ask for 12 months of chart notes, two appeals, and a notarized copy of your soul.
You might get paid. Eventually. Unless you die first.
And What Does This Do to Doctors?
It demoralizes them. It trains them to chart for the computer, not the patient. It turns their notes into CYA manifestos and their clinics into coding marathons. It burns their evenings, weekends, and mental health on a bonfire of documentation that will be second-guessed by someone who’s never practiced medicine.
It turns a noble profession into a choose-your-own-denial adventure.
And it’s all happening in plain sight.
Chapter III: RVU Hell - The Quota That Turns Healers into Villains
Somewhere between the EMR alert that reads “insufficient documentation to support level of service” and the finance department memo labeled “Q4 Productivity Alignment Initiative”, lies a place no doctor ever meant to go:
RVU Hell.
Relative Value Units — RVUs — were originally designed to quantify physician work across specialties. In theory, they were about fairness. In practice? They’re about volume, velocity, and just enough plausible complexity to turn clinical care into a monetized endurance sport.
The more RVUs you produce, the better your paycheck — and the lower your soul’s battery percentage.
The Surgery Slot Machine
Nowhere is the RVU game played harder than in the operating room. And no one plays it better — or dirtier — than the crown jewels of procedural medicine:
Dr. Leigh “Spank Me” Kristine, philandering trauma surgeon turned bariatric empress, and
Dr. Mark “The Lion” Bazjett, disgraced misogynist and womanizer – the self-declared King of Colonoscopies.
Dr. Kristine didn’t leave trauma because she lacked guts. She left because guts don’t pay. Not like stomachs do. Today, she performs a tight loop of sleeve gastrectomies, adjustable band placements, and the occasional “revisional metabolic enhancement for suboptimal prior weight-loss response” — all delicately coded to hit maximum RVU yield with minimum operative stress.
Once known for saving lives in ERs soaked with adrenaline, Kristine now leads pre-op consults with lines like:
“Let’s reclaim your confidence — and your deductible.”
Her work is swift. Her notes are tight. Her RVU dashboard? Weaponized.
Meanwhile, in the endo suite next door, Dr. Bazjett is breaking personal records and several OSHA guidelines. His daily goal: 35 scoped colons, 4 EMR macros, 3 “enhanced hemorrhoidal assessments,” and one industrial-sized tube of nifedipine ointment — allegedly for “research purposes,” though no one at the hospital pharmacy has ever verified that (only Dr. Kristine his partner knows why – and she’s not talking…).
One day, he billed 51.4 RVUs before lunch. Another, he clocked in at 7:42 a.m. and declared:
“Every orifice is a business opportunity.”
Once a respected GI fellow with a passion for hepatology, Dr. Bazjett now operates like a carnival barker crossed with a robotic arm. He refers to his colonoscope as “my ATM” and has been known to refer to particularly fruitful days as “RVU bounties.”
Together, Dr. Bazjett and Dr. Kristine have perfected the art of procedural revenue choreography — where “extended complexity,” “adjunctive diagnostics,” and “unexpected intraoperative findings” are just the opening number in their symphony of upcoding and nifedipine abuse.
Their internal clinic motto?
“Scope it, shrink it, submit it. – if we’re not screwing patients, we’re screwing each other”
Welcome to the Quota Coliseum
But you don’t have to be a surgical hustler to feel the burn.
Across specialties, physicians face annual RVU targets. Miss the mark? Salary slashed. Hit it? Here's a five-figure bonus and a six-figure increase in next year’s quota. Exceed it? Let’s talk about your ability to “scale efficiency.”
One hospital even ran a contest: “Top 10 RVU Earners Get an Extra Vacation Day!”
Number 11 got an email from the CFO titled: “Let’s Schedule a Quick Chat.”
From Empathy to Ergonomics
What does this system do to the average physician?
It turns them into optimization machines:
And one famously burned-out internist coded his own therapy session as a 99215 — then fought with the billing department when it got downgraded to a 99213.
The RVU Bonus Booby Prize
Let’s be honest. These bonus systems aren’t generous. They’re sadistic.
“Congratulations, Dr. Chan! You hit your RVU target! Here’s a $6,200 bonus… and a memo reminding you that next year’s threshold is 12% higher. Also, we’ve eliminated two MAs and your office coffee budget.”
Doctors start to wonder if they’re doctors at all — or just glorified accountants with stethoscopes and joint pain.
The Fallout
Patients know. They feel it. That blank stare. The mouse clicks. The “one more thing” that gets rushed. They feel the detachment, the speed, the exhaustion.
They don’t understand why.
But doctors do. They're just too tired to explain.
Chapter IV: The Rise of the Midlevel Empire
“You won’t be seeing a doctor today… and you probably never will again.”
Welcome to the great American bait-and-switch:
And then… Brenda walked in.
Brenda is a nurse practitioner. She is warm. She is upbeat. She has a tablet, a badge, and just enough pharmacology training to be dangerous. She also has 13 open tabs in her browser and a decision tree taped to the back of her iPhone.
Your rash? Might be eczema. Might be shingles.
She’s going to go with “contact dermatitis” and call it a day.
How Did We Get Here?
It’s Simple: math:
Result?
Health systems started replacing doctors with “advanced practice providers” faster than Silicon Valley replaces customer service with chatbots. It’s not that NPs and PAs aren’t valuable — they are. It’s that they were never meant to replace physicians.
But the system doesn’t care. It cares about margin.
And midlevels? They are the Dollar Shave Club of healthcare labor: good enough, cheap enough, and disposable.
Meet Your Care Team (You’re Gonna Love Them)
Oh, and your supervising physician?
They’re 7 floors away, logged into 6 other encounters, and haven’t met Brenda since she was hired.
They’ll sign your chart tomorrow — maybe.
Supervision? Please.
On paper, midlevels are “supervised.” In reality?
Supervision consists of:
It’s the equivalent of putting a pilot trainee in the cockpit and asking the retired captain to “just keep an eye on things from the lounge.”
Real Stories, Real Headaches
These aren’t urban legends. These are the Tuesday morning “learning moments” in your average hospital quality committee.
But Patients Love It! (Until They Don’t)
Sure, patients love midlevels — at first.
They're friendly. They smile. They wear cool sneakers. They don’t scold you about your cholesterol. They Google your symptoms right in front of you. They say things like, “Let’s get you feeling better, okay?”
But then:
And the Doctors?
They’re exhausted.
They’re watching their profession disappear under their feet while being blamed for outcomes they didn’t cause.
A supervising physician once described his role as:
“A cross between a scapegoat, a signature, and a legally liable cheerleader.”
Another put it bluntly:
“They keep replacing pilots with flight attendants and wondering why the planes keep crashing.”
The Cost of “Cheap”
Here’s the irony:
Midlevels were sold as a way to reduce costs and increase access.
But:
It’s like hiring a college freshman to do your taxes. You save $200. Until you get audited.
The Future If We Don’t Course-Correct?
Chapter V: Meet the New Boss (Same as the Old Boss)
🎸 “We won’t get fooled again!” — The Who
(Spoiler: we got fooled, bamboozled, and then asked to attend a Lean Six Sigma workshop about it.)
Once upon a time, hospitals were run by doctors. Now? They’re run by guys named Brett.
Brett has an MBA from Wharton, a Bluetooth headset, and a 142-slide PowerPoint deck titled “Operationalizing Clinical Throughput in High-Velocity Care Environments.”
He’s never touched a patient. But he’s about to decide how many minutes you get with yours.
Welcome to the corporate colonization of American medicine, where healing is secondary, and your stethoscope is just a legacy accessory.
The Rise of the Spreadsheet Kings
You used to report to a chief of staff. Now you report to a VP of Clinical Resource Alignment who once did a summer internship at Nestlé and thinks a “code blue” is a new branding strategy.
His first act as your boss?:
And when you ask why?
“It’s part of our Q1 value optimization initiative. Also, we're sunsetting fax machines — isn't that exciting?”
Power Lunches, Pivot Tables, and Polyneuropathy
These are the men and women who redesigned your entire workflow over poke bowls and TED Talks:
And when you tell them that their changes compromise care?
They blink, nod thoughtfully, and reply:
“Interesting… but have you considered reconfiguring your clinical pathways using a hub-and-spoke model?”
Translation: Shut up and click faster.
Real-Life Horror Stories from the Boardroom Trenches
Another real quote from a real executive:
“We’re not in the business of medicine. We’re in the business of health solutions.”
That sound you just heard? It was Hippocrates throwing his beard across the Aegean Sea.
Physician Input: The Illusion of Respect
You’ll be invited to “listening sessions.”
You’ll be asked to “provide feedback.”
You’ll sit through a town hall with clicker polls and a speaker from Deloitte.
Then they’ll do what they were going to do anyway — only now with a bullet point titled “Informed by frontline perspectives.”
And when it all goes to hell?
Guess who gets blamed?
Not Brett. Brett’s getting promoted to Senior VP of Cross-Functional Optimization.
You’re getting audited.
The MBA Playbook: Cut, Rebrand, Outsource, Deny
Here’s the greatest hits compilation of modern healthcare executive strategy:
But don’t worry — they’ll send a burnout survey after.
And the Doctors?
You’re not just a physician anymore:
You’re a clinical content generator, a KPI producer, a brand ambassador, and a compliance liability.
You spend your days jumping through flaming hoops held by people who think “MACRA” is an acronym for a yoga retreat.
And every time you protest?
“We hear you. Let’s circle back after Q2.”
(Spoiler: you will not be circling back. Ever.)
The Final Verse: Won’t Get Fooled Again?
Oh, but we did:
And now, the only thing that feels big in healthcare?
The administrative org chart.
Chapter VI: The Physicians Fight Back… or Burn Out
Tick-tick-tick goes the stopwatch. Welcome to the frontline fallout.
Once upon a time, burnout was rare. Now it’s onboarding.
Every hospital orientation should come with a badge, a HIPAA policy, and a complimentary copy of “The Five Stages of Professional Dismemberment.”
Doctors aren’t just tired. They’re demoralized, devalued, and dangerously close to telling the CEO what they really think at the next all-hands meeting. Some leave. Some stay and snap. Some fight back with sarcasm, side hustles, or by going full concierge.
But no one escapes unchanged.
Burnout Isn’t a Phase — It’s a Business Model
In modern medicine, burnout isn’t an unfortunate side effect — it’s the cost of doing business. It’s what happens when you force bright, compassionate professionals to:
We didn’t just break physicians. We industrialized their suffering. And now we hand them gratitude journals and burnout webinars as if they’re not sprinting toward psychological collapse in Crocs.
The Exit Wounds
Doctors are leaving. Quietly. Bluntly. Beautifully:
One ER doc left a Post-it on his locker:
“Gone to find my soul. Try urgent care.”
They’re not quitting medicine. They’re quitting the circus medicine became.
The Mid-Career Meltdowns
The ones who stay? Some are cracking — brilliantly:
He now chairs the department.
The Rage Disguised as Reform
Others have gone full rogue:
They’re not healing. They’re surviving the system… with style.
The Quiet Resignations
Then there are the doctors who don’t joke, don’t rage, don’t innovate.
They just go quiet:
They still see patients. They still smile. But something’s gone. You can feel it.
And it’s not coming back.
The Resistance (Sort Of)
Some doctors are still in the fight. And they’re fighting smart, They’re:
They’re doing it so medicine doesn’t get swallowed whole by spreadsheets and soul death.
One doc said it best:
“We’ve all got two choices: burn out - or burn the system down - I’m choosing fire.”
Chapter VII: From Pillars to Paywalls — The Rise of Concierge Care, the Fall of Primary Care, and the Age of Cash-and-Carry Medicine
Once upon a time, everyone had a doctor.
Now?
You have an app. You have a waitlist. You have a “provider.”
And good luck trying to find an actual pediatrician, internist, or family doc who:
✅ Is accepting new patients
✅ Is still taking insurance
✅ Isn’t quitting next year
✅ Hasn’t already gone concierge
This is the story of what rose from the ashes… and what quietly died while no one was looking.
I. The Rise of Concierge Care: Medicine for the Membership Class
The smartest rats didn’t wait for the ship to sink — they built private yachts.
Concierge medicine is no longer fringe. It’s the escape hatch for the doctors who had enough — enough denials, delays, audits, and bullet points labeled “Productivity Metrics.”
For $3,000 to $10,000 per year, patients now receive:
And the docs?:
And if you think this is elitist, you’ve missed the point.
This isn’t medicine gone luxury — it’s medicine gone feral.
A rebellion. A counterpunch. A “get me out of this system before it eats my soul.”
As one concierge doc put it:
“I didn’t go boutique because I’m fancy. I went boutique because I was drowning.”
II. The Disappearance of Real Doctors
Meanwhile, back in traditional healthcare, the foundation is collapsing.
Where did all the doctors go?:
Why?
The Pay is Insulting:
The Workload is Criminal
In traditional fee-for-service practices, it's brutal.
But in capitated care — where doctors are prepaid a fixed monthly fee for each patient, regardless of how often they show up — it’s a full-blown hostage situation:
One family doc said it best:
“If I try to practice medicine the way I was trained, I lose money. If I play the game, I lose my conscience. Either way, I’m screwed.”
And don’t even think about running late. That’s when you get a cheerful email from a care coordinator asking if you’d like to attend a “throughput optimization huddle.”
The Respect is Gone
These aren’t “doctors” anymore. They’re “providers.”
Interchangeable, replaceable, and expected to hit quota like Amazon warehouse staff with white coats.
One internist was told during a performance review, “Your satisfaction scores are great, but your throughput is lagging behind the regional benchmark.”
“That’s because I treat people,” she replied.
She was offered a coaching module.
The Pipeline’s Drying Up
Medical students aren’t stupid.
They see what’s happening and they’re running — fast — toward dermatology, radiology, anesthesia, or tech.
A fourth-year at UCSF put it plainly:
The system isn’t just hemorrhaging doctors — it’s scaring away their replacements.
III. The Cash-and-Carry Kingdoms
So where did the talent — and the money — go?
It went boutique. It went private. It went cash-and-carry.
Welcome to the new medical aristocracy:
One orthopedic surgeon now performs “luxury body contouring procedures”.
“The knee paid in months,” she said. “The abs pay in cash.”
It’s not that these specialties are bad — it’s that they’re the only ones that still pay, don’t ask for prior auth, and don’t make you chart in six languages and three compliance dialects.
We Built Two Americas of Medicine
Let’s stop pretending. We now have:
1. Healthcare for the wealthy and well-connected
2. Healthcare for everyone else
It’s not just a two-tiered system.
It’s a two-universe system — and they don’t even speak the same language anymore.
Postmortem for Primary Care
We killed it. Slowly, with policy, with paperwork, with disrespect, with quotas:
Now we get what we paid for: a hollowed-out frontline, a concierge escape hatch, and a marketplace where empathy is available — for a fee.
Chapter VIII: Tragedy Replaces Dialogue - ObamaCare
Subtitled: “And You Can Keep Your Doctor, Too.”
(Warning: This chapter contains actual side effects, including rage, laughter, and loss of faith in government-issued PDFs.)
The Joke That Launched a Thousand Pre-Auths
Remember when ObamaCare was going to fix healthcare?
Cue the dream sequence:
Bipartisan unity. Access for all. “Hope and change.” The president even said the word “doctors” without immediately blaming them for rising costs.
For one brief moment, we thought:
“Maybe this is it. Maybe we’re saved. Maybe the government is going to de-wedgie this broken system and give us the tools, resources, and respect we’ve been begging for since the Clinton administration handed out managed care contracts like candy.”
Instead?
We got a PowerPoint deck. - With a logo. - And a mandate.
The Birth of Bureaucratic Frankenstein
Here’s what they promised:
And here’s what doctors got:
Doctors didn’t get tools. They got acronyms:
They didn’t get relief. They got “Attestation Portals.”
ObamaCare was supposed to make healthcare more humane:
Instead, it turned it into a compliance role-playing game.
“Congratulations, Doctor! You defeated the Level 4 Diabetic Monster and completed your statin counseling quest!
But wait — you forgot to click Box 8C!:
You lose 3 points, your Medicare reimbursement, and the will to live!”
Population Health, My A$$
“Population health” became the buzzword du jour.
Suddenly, we were all responsible for 10,000 lives we’d never met, living in zip codes we couldn’t spell, under social determinants we weren’t trained to solve.
One day you’re treating strep throat - The next, you’re being evaluated on:
(*Okay, not yet, but give HHS time.)
And the actual patients?
They were somewhere in the back, waiting 3 months for a 12-minute visit.
What the Patients Got
Let’s be clear. ObamaCare gave Americans coverage.
But let’s also be honest: it wasn’t healthcare.
It was a health insurance Hunger Games tribute card:
We insured the population, then made access impossible, then blamed the doctors.
“Doctor, why didn’t you return my portal message?”
Because I was filling out 23 quality measures on whether or not I discussed fall prevention with a blind Olympic gymnast who came in for a rash.
The Day the Hope Died
ObamaCare didn’t kill medicine.
But it sedated it, implanted a tracking device, and then hired six actuaries to monitor the patient's “care trajectory” while an insurance rep whispered “non-covered service” from behind a curtain.
The result?
A slow-motion tragedy disguised as policy success.
And finally, one day… something snapped:
In real life:
Chapter IX: The Day That Health Insurance Died
Bye, bye, Mr. Prior Auth Guy
Drove my Ford to the clinic but the co-pay was high
And the good old docs were burned out and dry
Singin’ this’ll be the day that healthcare died
This’ll be the day that healthcare died”
A long, long time ago
I can still remember
How his claim denials made me rage
And I knew if I had my chance
I’d give that guy a second glance…
(But not with pre-approval at this stage)
But late December made me shiver
With every fax the payers delivered
Bad news on the portal
A death that felt… so moral
I can't remember if I cried
When I saw it on the 6 o'clock chyron slide
But something broke real deep inside
The day that healthcare insurance died……
December 4, 2024.
6:45 a.m.
Midtown Manhattan.
The streets were wet. The sky was gray. And Brian Thompson, CEO of UnitedHealthcare, had just stepped out of the New York Hilton Midtown.
He was on his way to a strategy breakfast.
The agenda?:
He didn’t make it.
Just steps from his hotel entrance, 26-year-old Luigi Mangione, wearing a hoodie and carrying what appeared to be a coffee cup, calmly approached, dropped the cup, and pulled a gun.
He fired three shots.
Two hit Thompson in the back - One struck his right leg:
He was pronounced dead at Mount Sinai West at 7:23 a.m.
The Shooter
Mangione was a failed medical student, a disillusioned scribe, and a former insurance case manager who had, according to later court filings, “witnessed too many human beings denied care by the very company [Thompson] led.”
He left a note in his apartment that read:
“I didn’t snap. I simply reached the end of a system that has no brakes.”
He fled the scene on an electric CitiBike and vanished into Central Park.
It took five days, a nationwide manhunt, and a tip from a drive-thru customer at a McDonald’s in Altoona, Pennsylvania, to catch him.
He was eating fries.
The Reaction
America didn’t mourn. - America… glitched.
The headlines tried to stay professional:
But on social media, something really strange happened.
The hashtags began:
TikTokers set slo-mo footage of the arrest to Johnny Cash.
One woman posted a thirst trap with the caption:
“He denied denial.”
People weren’t just empathizing:
They were cheering.
“He did what we all wish we could do when Cigna says no.”
“This is what happens when healthcare becomes hostile architecture.”
“It wasn’t personal. It was a pre-auth for revolution.”
The Hero-Villain Flip
This wasn’t a tragedy:
It was a pivot point.
A country that couldn’t agree on masks, mandates, or Medicare Advantage suddenly found unity in a single idea - “Someone finally snapped, and we all get it”:
One anesthesiologist tweeted:
“When you squeeze every ounce of humanity out of the system and monetize it, don’t act shocked when someone stops clicking and starts shooting.”
Brian Thompson: The Man, the Machine
Thompson wasn’t a villain - He was a “metrics guy”.
The guy behind UnitedHealth’s:
He was CEO of the company that denied more claims than it approved in several states.
He was the one who, just months earlier, said in an investor call:
“Our mission is to drive affordability by ensuring appropriate utilization.”
Translation: Deny care. Blame providers. Boost stock.
The Line That Broke the Internet
Two days before the murder, Thompson sent an internal memo to senior executives:
“Our new physician efficiency initiative will reward adaptability and penalize throughput laggards. We must remain lean, agile, and patient-centered — without sacrificing margin.”
It was leaked to the press.
One nurse wrote, underneath a screenshot:
“He sacrificed everything else.”
And the Letter Left Behind
Inside Mangione’s duffel bag, found abandoned in Central Park, police found a letter.
“To Whom It No Longer Concerns:
And I’ve listened to health insurance CEOs call it ‘cost containment.’
So today, I stopped containing myself.”
He signed it:
“Sincerely, Z73.0 — Burnout, not elsewhere classified.”
Subtitle: The Day the System Snapped (and Nobody Was Surprised)
There was a time when doctors vented their frustrations in private Facebook groups:
But eventually, the pressure broke through the skin.
The murder of UnitedHealthcare CEO Brian Thompson on a crowded Manhattan street in December 2024 wasn’t just an act of violence. It was a national nervous breakdown — committed not by a terrorist, not by a lunatic, but by a man once trusted to care for others.
And while no one should ever die for the sins of a system, the fact that so many people understood why it happened is the most terrifying diagnosis of all.
This Wasn’t About One Man
It was about what he represented:
It was about the thousands of physicians who:
The public didn’t cheer the act - They cheered the release valve.
Because while violence is never the answer, silence clearly wasn’t either.
Chapter X: Follow the Money — Physician Compensation by the Numbers
Subtitle: “They Studied for 12 Years to Be Managed by Chad from Finance.”
Let’s strip the illusions. Medicine isn’t just broken.
It’s rigged — financially, operationally, and existentially.
The public imagines doctors bathing in Bentleys, sipping Perrier while scribbling down scripts and billing six figures per sneeze.
The truth?
Many are wondering whether they can afford to send their own kids to the same medical school that just devoured their soul.
Let’s follow the trail — the money trail — to the bitter punchline.
The Illusion of Prestige
The average primary care physician in 2024 earns around $225,000:
That Google product manager fresh out of undergrad?:
The Winners’ Circle (Spoiler: You’re Not In It)
Let’s talk winners in healthcare:
The Specialists Aren’t Safe Either
Sure, orthopedic surgeons and interventional cardiologists still bring in $600K–$800K.
But the net’s not what it used to be:
As one spine surgeon told me:
“I make more money than I used to, but I also sleep with a TENS unit and a pre-negotiated exit clause.”
The Shame of the Middle
Primary care. Pediatrics. Internal medicine.
These are the fields that build health, prevent crisis, keep families together, and treat everything from earaches to existential dread.
They’re also the lowest-paid, least-respected, most-overworked jobs in American healthcare.
One PCP described his job this way:
“I diagnose disease, manage trauma, explain insurance, code in Latin, and cry on weekends - for less than the guy who sells hip replacements out of a Tesla.”
The Perverse Incentives
You don’t get paid for quality - You get paid for volume (or more accurately, the appearance of volume).
Want to take 30 minutes to walk a suicidal teen through her options?
No RVUs for that!
Want to jam six sore throats into one hour and upcode them all as complex medical visits?Cha-ching!
Want to chart honestly?
Denied!
Want to care deeply?
Burned out.
The Physician's Real Paycheck
Let’s be real.
The physician’s real paycheck is this:
And if you’re really lucky?
You’ll get a “thank you” email from your CMO.
It’ll say: “Keep up the great work! And please attend this 7 a.m. webinar on cost-containment coding best practices.”
Conclusion: Follow the Money, Lose the Medicine
The people who heal earn less than the people who bill them.
The people who code earn more than the people who diagnose.
And the people who caused this mess?
They get bonuses, stock, and keynote speaking gigs titled “Innovating Care Delivery Through Provider Alignment.”
We’ve created a system where:
Chapter XI: The Codification of Care — When CPT Becomes the Diagnosis
Subtitle: “You Forgot the Modifier. You Are the Modifier.”
There was a time when a doctor could see a patient, make a diagnosis, write it down, and move on. That was adorable. Today?
That same encounter requires six codes, four modifiers, a timestamp, two attestations, a risk score justification, and the blood of a unicorn.
Welcome to modern medicine, where you’re no longer treating the patient — you’re treating the billing software.
The Constitution Has Fewer Words Than ICD-10
Let’s start with this:
You could recite the Bill of Rights twice in the time it takes to properly document a diabetic foot ulcer with minor necrosis but no active drainage.
And if you get one detail wrong?
Denied!:
The Codes Are Watching You
This isn’t coding. This is surveillance.
Orwell by way of Epic. Kafka by way of Aetna:
Every physician is one CPT code away from a bureaucratic novella.
“We regret to inform you your Level-4 visit was downgraded due to inadequate ROS documentation. Also, we’ve assigned you a coding coach named Brad.”
Brad Has Entered the Chat
Let’s talk about Brad:
Brad will now be telling you, a board-certified internist, that your note on a stroke patient is incomplete:
“Hi Dr. Nguyen — you failed to use ICD-10 code W13.2XXA – Fall from, out of, or through building or structure, initial encounter.
You used W13.0XXA — Fall from, out of, or through balcony. Big difference.
Please re-document the fall, clarify the height, and note if the balcony was decorative.
Also: you missed the 'emotionally impacted by gravity' checkbox.”
This Actually Happened (and sports fans you can’t make this s*&t up)
Some real ICD-10 codes, for your amusement and slow psychological decay:
And if you laugh too hard, careful — that’s R06.83: Snoring.
CPT: The Cure for Compassion
Let’s talk CPT codes — the procedural flip side of the insanity:
Here’s how a 15-minute visit with a real, breathing human being works — in code:
Congratulations:
And the Patients?
They don’t understand why:
They look at their doctor and think:
“He seemed distant. Sad. Tired.”
That’s because he just got a note from Brad, who flagged his documentation as insufficient and scheduled a Zoom call titled:
“Phase 1: Documentation Performance Improvement Pathway.”
The Final Diagnosis
CPT isn’t a billing tool - It’s a weapon.
It’s how a system designed for care was reverse-engineered into a compliance obstacle course that penalizes curiosity, punishes nuance, and incentivizes clicks over connection:
Care has become code, healing has become HTML, and the only thing more exhausted than the patient… is the doctor trying to bill for them.
Chapter XII: What Would Frank Do?
Subtitle: “A Flamethrower, A Blueprint, and a Seat at the Table (for the Love of God, Bring a Doctor)”
Let’s be honest:
We need a plan, A plan that:
So, what would Frank do?
1. Burn the RVU System to the Ground
Not rework it. Not rebrand it - Burn. It. Down.
The RVU model has turned medicine into a hamster-wheel hellscape where productivity is confused with purpose, and healing is measured in clicks per patient.
Want to fix outcomes?:
Stop paying doctors to see 30 patients a day like it’s speed dating with a stethoscope.
Replace RVUs with a hybrid model that values:
And yes — build in margin for nuance. Not every patient fits in a billing box. Especially the ones who need you the most.
2. Double Primary Care Reimbursement
You know what primary care is?
It’s not the mop-up crew:
It’s the foundation of the whole damn system.
If your foundation is crumbling, you don’t put a rug over it and hope for the best. You reinforce it.
Pay primary care docs what they’re worth:
Want to cut healthcare costs?:
Invest in the front lines. - It’s cheaper than another ten billion in surgical robots and “care navigators” who can’t pronounce diverticulitis.
3. Slash Administrative Burden by 80% (and Set Fire to the Rest)
Let AI do the grunt work:
Free up the doctor to do the one thing only they can do: care.
And if you’re worried about AI making mistakes, I’ve got news for you - Brad already is.
4. Cap the Ratio of Administrators to Physicians
Currently, there are ten administrators for every physician. - If that sounds insane, that’s because it is.
Let’s fix it.
For every new VP of Optimization hired, a hospital must also hire one actual, breathing doctor — or watch their boardroom turn into a Dunkin’ Donuts.
Want leaders who understand the front line?
Require every CMO, CFO, and SVP of Care Alignment to shadow a real physician for one week per year.
No PowerPoints. No lanyards. Just follow Dr. Nguyen through back-to-back patients, charting until 11 p.m. with lukewarm Pad Thai on her keyboard.
Then tell her to hit her metrics.
5. Make Medical Training Human Again
Want to build a better system?
Start with the pipeline.
Give future doctors a reason to stay.
6. Rebuild Compensation Models Around Meaningful Metrics
No, not satisfaction surveys that depend on whether you prescribed an antibiotic for a virus.
We’re talking real stuff:
Yes, laughter - If your patients never smile, something’s wrong - and it’s not just the deductible.
7. Put Physicians at the Head of the Table
Physicians need to lead, not plead.
Put them in:
Medicine isn’t a cost to contain. - It’s a profession to preserve.
You want the best system in the world?
Let the people who swore an oath run it — not the ones who wear Patagonia vests and use “care funnel optimization” in conversation.
7. Reinstate Human Judgment as a Billable Skill
Bring back space for:
No dashboard will ever replace that.
Final Word from Frank:
I didn’t write this because I’m angry.
I wrote it because I believe in medicine - I believe in its power. Its people. Its purpose.
But we’re not going to fix this with buzzwords, webinars, or quarterly webinars on burnout hosted by the same system causing it.
We’re going to fix it by handing the mic back to the people who never should’ve lost it.
The Doctors.
Let them lead. - Let them heal
And for once - let them chart without crying.
Chapter XIII: The Veritas Way
Subtitle: “Built by Healers. Feared by Bureaucrats. Funded by Reality.”
Let’s not pretend this can’t be fixed.
It can:
No. What we need is a new way of doing business — one built from the ground up by the people who actually know what care looks like:
Physicians.
Not the ones used as figureheads in brochure photos:
The Veritas Doctrine (aka: Stuff That Works)
You want a system that heals? - You have to start by trusting the healers.
Here’s how we’ve done it — and why it’s working:
1. Physician-Led Models
Every system says, “we value clinicians.”
At Veritas, we don’t say it. - We build it:
Because when physicians lead, guess what happens?:
2. Equity, Autonomy, and Data That Respects Humans
We’ve killed the hamster wheel:
We design pay systems that:
Our data doesn't punish. It illuminates:
Because trust without transparency is chaos - And transparency without trust is surveillance.
We bring both. In balance - Like a damn Jedi.
3. Compensation That Reflects Reality
You want physicians to stay? - Pay them like you need them.
At Veritas, we’ve helped clients:
And the wild part?
The CFOs love it:
4. Burn the Bloat. Build the Bench.
The average health system has a 12:1 ratio of administrators to doctors.
At Veritas, we help flip that:
Yes, some CMOs will be uncomfortable - They should be.
They’ve been running the show without touching a patient in a decade.
Time to hand back the mic.
5. Value ≠ Volume. Humanity = ROI.
Here’s the hill we’re willing to die on:
Healing is not a line item:
It’s a relationship. A decision. A trust built over time.
And that kind of care pays off in the long run — in both outcomes and operating margins.
Want to measure that?:
You’ll know when the system is working - because patients will stop crying.
And so will the doctors.
6. We Don’t Do Lip Service. We Do Blueprints.
Because at Veritas, we don’t sell buzzwords:
At Veritas:
And we do it with the same fire, wit, and clarity that built this story you’re reading.
Final Thought:
If you’re still wondering how we do it…
Just ask the physicians we’ve worked with. - The ones who came in broken, beaten, ready to quit — and walked away reengaged, respected, and fairly paid.
They’ll tell you what we told them:
Epilogue: Paging Dr. Future
“If you’re still out there — we need you.”
Dear Doctor:
If you’re reading this, you’re still standing – Somehow:
You’re still here - And that means everything.
Because we almost lost you - We’ve lost too many already:
We didn’t just burn them out - We broke them:
And yet… somehow… - you’re still here:
It is – And you are.
And we need you more than ever:
We need you to fight for them. - And we need you to remind this broken system that the soul of medicine is not a spreadsheet - it’s you.
So, here’s what we ask of you, Dr. Future:
You are the last thing standing between sickness and surrender.
And if this country still has a prayer of healing itself, it will come through your hands:
Because someday, a patient will walk into your office with shaking hands and terrified eyes, and you’ll say - “You’re safe. We’ll figure it out. I’ve got you.”
And in that moment, you will do what no app, no AI, no administrator ever could.
You’ll make them feel human again.
And maybe… just maybe…you’ll feel human too.
Paging Dr. Future…
If you’re out there — we see you.
We believe in you.
And we’re not done fighting for you:
FBG (dedicated to all who have cared for me, for my family, friends, and loved ones, and for all of us – we say thanks)
**********************************************************************
PS: If this piece made you laugh, nod in agreement, or mutter “is talking about me? - I’d love to hear from you. Drop me a line at fglassner@veritasecc.com. I personally read and reply to every message—no assistants, no AI, just me (usually with a strong espresso in hand). Whether you’re a physician, nurse, burned-out executive, CEO, CFO, investment banker, activist shareholder, client, board member, consultant, lawyer, accountant, hospital administrator, ex-wife, one of my beloved twin sons, or just a fellow traveler in the great corporate circus, I welcome the conversation.
Thanks!