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Ms Grace Chen knows to avoid the perfume section in the department store. At 53-years-old, she has lived with asthma her entire life. Scented perfumes and other “triggers” can suddenly cause her airways to spasm, sending her into a fit of wheezing. Today, she is not entirely sure what set off her symptoms, but she could feel her chest tightening up as it became more and more difficult to catch her breath, a sensation that she has experienced many times before. She reached into her purse to take out her inhaler and took a few puffs. She still felt like she was trying to breathe through a snorkel to get the air down to her lungs. Realizing that she may need help, she asked her son to drive her to a nearby urgent care clinic.

At the urgent care clinic, Ms Chen is evaluated by a physician, given a breathing treatment, and undergoes an electrocardiogram (EKG). Following the breathing treatment, she continues to have significant wheezing and shortness of breath, so the urgent care clinic physician coordinates for an ambulance to take her to an emergency room across town. Ms Chen has had to visit the ER for her asthma before, but it has been a number of years since the last episode that was this bad.

In the ER, she is promptly placed in a room and evaluated by an emergency medicine physician. Ms Chen undergoes further breathing treatments. A chest x-ray is taken, blood is drawn for labs, and another EKG done. Her labs are ok, her chest x-ray is clear, and her EKG remains normal. The physician then decides to obtain a chest CT (computed tomography) scan “just to be sure nothing was missed.” The CT scan does not reveal any significant abnormalities. Following more breathing treatments and an intravenous administration of solumedrol (a steroid), she improves. She ultimately is discharged home with self-care instructions, including directions for using her home inhalers and a prescription for oral steroids.

In Ms Chen's mind, this entire shortness-of-breath experience was a single event, caused by a single disease—an asthma exacerbation likely triggered by an environmental allergen. However, the urgent clinic will bill separate fees for the physician evaluation, the breathing treatment, and the EKG. The hospital will send another bill that charges separate fees for the physician evaluation, the chest x-ray, chest CT, the intravenous steroids, the lab work, the EKG, the breathing treatments, and the radiologist's interpretation of the imaging studies. Ms Chen will be left to navigate the complex system of healthcare costs herself.

Medicine is a noble profession, built on the altruistic motivations of caretakers. But, it is hard to ignore the fact that perverse incentives that require clinicians to “do more” to get paid will predictably result in more medical care. As in Ms Chen's case, treatments and procedures are paid for a la carte, ...

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