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The Cost Beast and the Quality of Life Serpent

Little is actually known about the Cost Beast and the Quality of Life Serpent.  Some claim they don’t exist.  They have rarely actually been seen, with notable exceptions – usually by young children who seem to have more sensitive eyesight when it comes to monsters.

But many others claim that both the Quality of Life Serpent and the Cost Beast exist based on the undeniable evidence of their presence, even if they’re invisible most of the time.  Maybe they’re related to Big Foot;  every once in awhile we find a footprint or other evidence, but actual sightings and photographs are extremely rare.

So how do we know they exist?  Simple.  The evidence they leave behind.  Surprise medical bills, often from procedures we didn’t want or ask for, or out of network physicians we didn’t even know were involved with our care.  Unacceptable rates of death due to preventable medical error.  Poor or no reporting on quality measures to the public.  Use of procedures or medications that we can predict are more likely to harm us than help us.

We may not get to see these two demons, but they’re out there lingering in the shadows, just waiting to have their evil ways with us.  And they’re winning the Old Game, with quality of care (and thus quality of life) inconsistent at best, and about half of our national health care budget spent on waste and even more on overpayment.

Dossier – The Cost Beast

Job Description:  Con patients into paying for treatments they didn’t order, didn’t want, and that weren’t helpful to them.  Try to get them to  unwittingly use out of network providers and excluded benefits whenever possible.  When they do buy helpful treatments, get them to pay far more than market value.  Make pricing information so hard to get that consumers get discouraged and stop trying.  Deplete vacation, education, and retirement accounts to zero.  Then go for bankruptcy.

Suspected Birth Date:  Mid 1980’s

Favorite Food and Drink:  Anything that’s served in a hospital cafeteria.

Favorite Hangouts:  Pharmacies, hospitals, outpatient surgical centers, and insurance company corporate offices.

Favorite medical procedure:  Wallet-ectimy.

Favorite Quotes (both from Sun Tzu’s ‘Art of War’):

“The supreme art of war is to subdue the enemy without fighting.”

“Be extremely subtle, even to the point of formlessness. Be extremely mysterious, even to the point of soundlessness. Thereby you can be the director of the opponent’s fate.”

Greatest Fear:  Value based consumers.

Los Angles Police sketch artist rendering of The Cost Beast from a 2005 sighting by several witnesses.

Photo suspected to be The Quality of Life Serpent extracted from a fast food restaurant security camera, Charlotte, NC, September 2012.



The Quality of Life Serpent

Job Description:  No matter how good or bad people feel, make them feel worse.  Deprive them of the Quality of Life they deserve.  Encourage unhealthy lifestyle choices that rob people of their quality of life and drive them into the sick care system.  Once there, convince patients to consume tests, treatments, and medications that can be predicted to do more harm than good.  Especially if they’re expensive!  Hide whatever quality and outcomes data there is, and discourage providers from using it to improve.

Suspected Birth Date:  Mid 1960’s.

Favorite Food and Drink:  Twinkies, Big Macs, and frozen pizzas.  Loves doing shots of high fructose corn syrup, and rarely drinks alone.

Favorite Hangouts:  Grocery stores (the inner isles), fast food restaurants, and pharmacies.

Favorite medical procedure:  Anything high risk or low/no gain (ie high NNT and a low NNH), including many prescription drugs and  orthopedic or cardiac surgeries.

Favorite Quotes (frequently repeated by many people):

“Sure, Biggie Size me.”

“The more tests, medications, and procedures you can give me, the better!”

Greatest Fear:  Value based consumers.

Not much is known, or at least proven, about any actual employment or consulting arrangements that the Cost Beast or the Quality of Life Serpent have been engaged in.  We do know they’ve never filed income taxes.

But here are some accusations that have been made:

Both seem to have considerable influence in the pharma and medical device industries.  The Quality of Life Serpent is suspected to have been behind much of the recent direct-to-consumer marketing strategies, including personally coming up with commercial messages like ‘Of course it’s too hard to exercise and diet. Take our pills instead’.  He has even been clever enough to ‘medicalize’ normal human conditions and convincing doctors and patients alike that conditions such as PMS and ‘Seasonal Effective Disorder‘ are forms of depression, and merit prescription medications.  The result?  Tens of millions of people who thought they were basically healthy and just experiencing normal variations in mood are now diagnosed as having a condition, and are suddenly lifelong pharma customers.  Lately, he’s even diversified into children’s comic books.  Gotta brainwash the youngsters and prepare the next generation of customers!  The Cost Beast’s claw prints have often been found on pricing models for both industries, and a laptop with his login credentials was found to contain early drafts of Medicare Part D legislation that precludes Medicare from negotiating prices on prescription medications.  Beastie works every day nudging doctors to write prescriptions for brand name drugs, when clinically equivalent generics are just as good.  Between 2010-12, this alone accounted for $73 billion in avoidable overspending.

The Quality of Life Serpent also loves to create ‘educational’ materials for pharma and medical device vendors to use with physicians.  Who needs independent, unequivocal, clear, positive, supporting evidence when you’re writing the textbook?   And whenever The Quality of Life Serpent gets discouraged because patients or physicians start paying attention to valid, independent research, Comparative Effectiveness Studies or The NNT, he escapes to where he knows he’ll be safe and happy – the Clinical Trials process and peer reviewed literature publications.  Beastie works every day nudging doctors to write prescriptions for brand name drugs, when clinically equilivant generics are just as good.  Between 2010-12, this alone accounted for $73 billion in avoidable overspending.

Hospitals have never actually been accused of hiring either of these beasts, but many hospitals could be criticized for not doing more to keep them from sneaking into their institutions.   The Cost Beast loves to hang out down in the billing department, mess around with the Charge Master, and drop hints to the billers about how to un-bundle normal visits into huge, itemized lists of insanely inflated and impossible to understand line items.   Every month he checks the unchallenged billing error rate and has a hearty laugh.

The Affordable Care Act (commonly referred to as ‘Obamacare’) was initially very intimidating to both The Beast and The Serpent.  After all – look at the name!  The Beast can’t stand to see healthcare that’s affordable!  But while The Serpent was quaking in the corner after seeing how many mandatory services each plan had to include, The Beast had a stroke of genius.  Since all plans had to include these new services; and since 10+ million previously uninsured people would now have insurance; and since their actuarial history didn’t give them an accurate way to project payouts; the insurance companies had the perfect opportunity to raise premiums AND deductibles.  Virtually EVERYONE’s premiums went up – a lot – regardless of their utilization.  And when people needed care, especially primary care, the high deducible plans now meant many people were paying 100% out of pocket instead of just co-pay’s.  The net effect?  The Affordable Care Act ended up making care unaffordable for many, often resulting in self-denial of primary care for financial reasons, which further resulted in compromised Quality of Life.  For The Beast and The Serpent – a double win!   But this did end up having a down side, since it brought at least The Beast some unwanted attention in the nationwide press.  And Obamacare wasn’t all good news for Beastie and Serpie;  no more pre-existing conditions, no more annual limits; no more lifetime limits; and no more cancellations when people needed their insurance the most.  Oh well.  Win some, lose some.


Beastie and Serpie working as a team ...


“The problem is that we squander 50 percent of our health-care dollars on medical care that does not improve the health and well-being of patients. Poor quality is the primary driver of excess cost. In the U.S., we produce, consume and pay for a great deal of great medical care; the best medical care in the world is available in the U.S. when we do it right. But we don’t always do it right. We also produce, consume and pay for hundreds of millions of dollars of ineffective and low-quality care that takes money out of the system without returning commensurate value. It is this waste that drives the price of health care beyond our reach as a nation. We are all paying the tab.”

Dr. Robert Mecklenburg, Virginia Mason Medical Center, from Transforming Health Care:  Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience

Insurance companies and employers were some of the first to suspect that The Cost Beast was at work, and took steps to protect themselves and stomp him down.  Unfortunately, those steps – generally higher premiums and higher deductibles – didn’t actually hurt or discourage The Beast; it just caused him (or is it her?) to turn their attention to individuals and employees.  But The Beast wasn’t satisfied with higher premiums and deductibles;  that devious son of a gun actually figured out another way to stick it to individuals and employees with Narrow Networks and extended lists of excluded benefits.  Most providers saw the tricks The Beast was pulling and beefed up the language in their Informed Consent forms to cover themselves.   How could The Beast resist?  Consumers weren’t asking any questions about what they received or who provided it. And who reads an Informed Consent before signing?  Why not cash in and financially obligate patients to Charge Master rates?

It worked!  Surprise medical bills skyrocketed, as did personal bankruptcies due to medical bills, and The Beast’s job satisfaction was never higher.  Chaaaa CHING!


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