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Mr James Green is a 28-year-old man living in San Diego, California. He splits his nights between working as a server at a small restaurant, and his true passion—playing guitar in a local rock band. He is currently uninsured, but has always been healthy. This evening he was waiting tables at the restaurant when he began to have pain in his lower abdomen. He tried to ignore it and keep working but it steadily worsened. By the time he returned home from his shift, he was clenching his belly, uncomfortable and worried. Not knowing what to do or how worried he should be, he typed, “belly pain” into a search engine on the Internet. A list of “searches related to belly pain” returned1:

  • Appendicitis: “A serious medical condition in which the appendix becomes inflamed and painful.”

  • Gastroenteritis: “Inflammation of the stomach and intestines typically resulting from bacterial toxins or viral infection.”

  • Stomach flu: “A short-lived stomach disorder of unknown cause, popularly attributed to a virus.”

  • Irritable bowel syndrome: “A widespread condition involving recurrent abdominal pain and diarrhea or constipation, often associated with stress, depression, anxiety, or previous intestinal infection.”

James does not know if his abdominal pain could be something urgent like appendicitis or something “short-lived” like the stomach flu. He becomes very anxious about the emergency department (ED) and how much it might cost. This episode of abdominal pain could cost him about $100 for a simple urgent care visit, a couple thousand dollars for imaging, or tens of thousands of dollars for surgical treatment, and he has no way to know which it will be. He decides that he will try to “tough it out” a little longer. He lies down in bed, but by the middle of the night he is vomiting and curled over in pain. He calls a friend and asks him to come urgently to bring him to the hospital. He ultimately is diagnosed with a ruptured appendix from untreated appendicitis.

Adding to Mr Green’s initial uncertainty about access to care and how much it may cost is the fact that once a patient like him with severe abdominal pain arrives at the ED, he really has no way of knowing whether the care that his physician is ordering—and he is paying for—is the most appropriate for his condition. “Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made,” notes San Francisco General Hospital emergency medicine physician Dr Renee Hsia and colleagues in an article about variation in ED pricing for appendicitis.2 “Even if a patient did have the luxury of time and clinical knowledge to ‘shop around,’ we found … hospitals charge patients inconsistently for what should be similar services.”


In the early 20th century, physicians often ...

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