Every medical encounter in the United States is reduced to a billing code. That code decides what work is rewarded and what work is neglected. It determines whether physicians are paid to listen or to cut, whether prevention is supported or starved, and whether a patient is treated as a person or a transaction. It is not neutral. It is a hidden law written in private rooms, and it has reshaped American medicine into a system that produces inequity, waste, and preventable death.
When Medicare began in 1965, the government needed a way to pay doctors. By the 1980s the gap between specialist income and primary care income had become so extreme that Congress sought reform. The solution was to link reimbursement to the “relative value” of services. Instead of creating an independent public body, lawmakers deferred to the American Medical Association. In 1991 the AMA created the Relative Value Scale Update Committee, known as the RUC, which assigns “relative value units” to each service. Those units are multiplied into dollars by Medicare and quickly copied by private insurers.
The committee is dominated by specialty societies. Primary care has only token seats. The surveys used to estimate the time and effort of procedures have been shown to overvalue specialty interventions while undervaluing cognitive and relational care. The Centers for Medicare and Medicaid Services accepts more than 90 percent of the RUC’s recommendations. In practice, the AMA writes the national pay scale for medicine.
The surveys that drive this process are deeply flawed. Physicians self-report how long a procedure takes, how intense it feels, and how much effort it requires. These estimates are often inflated. A surgery that takes thirty minutes may be reported as taking ninety. Once codified, those numbers anchor reimbursement for years. Prevention and counseling have no similar inflationary leverage. The result is a pay scale that favors procedures, imaging, and intervention while systematically devaluing the time needed to listen, diagnose, and manage chronic conditions.
The bias is visible. A fifteen-minute visit centered on prevention is reimbursed at a fraction of a fifteen-minute procedure. Specialists often earn three to four times more than primary care doctors, not because of skill alone but because of how the code values their work. Medical students, burdened with debt often above $200K, follow the money. The result has been chronic shortages in primary care, pediatrics, and geriatrics, alongside surpluses in lucrative specialties. The workforce itself has been engineered by the code.
Payment rules also dictate time. Because primary care is paid poorly, physicians must see more patients in less time. The average primary care visit in the United States is 15 to 20 minutes. In nations with stronger outcomes, visits last 30 to 45 minutes. Short encounters push doctors toward shortcuts and stereotypes. Women and people of color are more likely to be dismissed or misdiagnosed because their symptoms do not match the textbook “classic” presentation. When the system rewards volume over listening, dignity becomes a luxury patients cannot afford.
The toll is measured in lives. Medical errors kill an estimated 80K to 100K Americans each year. Over three decades that amounts to more than 2.5M preventable deaths. Sepsis kills more than 250K Americans annually, with delayed recognition as a leading factor. Women are more likely to be sent home during a heart attack and many die within hours. Black women are three to four times more likely to die from pregnancy-related causes, a disparity recognized as largely preventable. More than 1.3M Americans ration insulin each year, with thousands dying from diabetic ketoacidosis. Asthma patients ration inhalers and some die from attacks that preventive care could have stopped. The billing system pays generously for amputations and dialysis while underpaying for continuity and counseling that would prevent these crises. Over the life of the RUC, the cumulative death toll from undervaluing prevention is well into the millions.
Bias magnifies the damage. Decades of studies show that women reporting pain are less likely to be believed, more likely to have their symptoms attributed to anxiety, and more likely to be given sedatives rather than diagnostic tests. In the case of heart attacks, women are more likely than men to be discharged from the emergency room, only to return in crisis or die within hours. Journalist Lisa Colagrossi collapsed from a brain aneurysm after warning symptoms were overlooked. Tennis champion Serena Williams nearly died after childbirth when her repeated concerns about pulmonary embolism were initially ignored. Kira Johnson, a 22-year-old Black mother in Los Angeles, died after her symptoms of internal bleeding were dismissed for hours. Each case illustrates how structural bias, compressed time, and undervaluing preventive vigilance combine to produce outcomes that could have been avoided.
The financial costs compound the tragedy. Malpractice lawsuits cost an estimated $55B annually, and behind those numbers are verdicts that reveal systemic flaws. In Illinois, a jury awarded $100M to the family of a boy left brain damaged after delays in emergency care where overwhelmed staff missed critical signs. In Florida, a family won $24M after a woman died of sepsis that could have been treated if her deterioration had not been dismissed. In Texas, a family was awarded $10M after their newborn died during delivery when complications went unnoticed. Each verdict is a measure of human loss and of a policy framework that forces rushed care. Defensive medicine adds billions more as doctors order tests out of fear, subjecting patients to radiation and unnecessary procedures while failing to address the underlying problem of too little time to listen.
Another practice born from these distortions is known as code switching. This occurs when providers alter billing codes to secure higher reimbursement. A counseling visit may be coded as something more procedural so that a physician can cover costs. While it may keep the practice solvent, it can harm the patient. A misclassified code enters the permanent record and can affect future insurance eligibility, raise premiums, or lead to denied claims. Patients may also be saddled with out-of-pocket charges if the substituted code falls outside their coverage. Code switching reflects the desperation of providers trapped in a system that punishes preventive care, yet it exposes patients to financial and medical harm that can follow them for years.
Audits have shown that more than 7 percent of all medical bills contain significant coding errors, and the majority of these errors increase costs for patients. The Office of Inspector General estimates that Medicare alone makes improper payments exceeding $25B each year, much of it tied to miscoding. Each year insurers deny roughly 50M claims, many citing discrepancies between services provided and codes submitted. Families often never know whether their denial stems from an honest error, deliberate code switching, or insurer tactics to reduce payouts. More than 60 percent of U.S. bankruptcies involve medical bills, and miscoding contributes to the churn of disputed charges that drag patients into financial ruin.
Real cases make this clear. In New York, a woman seeking therapy for postpartum depression discovered later that her visits had been coded as “major depressive disorder, recurrent severe.” That label followed her into the insurance system, leading to higher life insurance premiums and complicating her ability to obtain disability coverage years later. In California, a child with mild asthma was coded under a more severe classification so the pediatrician could be reimbursed at a higher rate. When the family applied for individual insurance, the insurer cited the code as evidence of a high-risk condition and denied affordable coverage. In Texas, a man who went in for a routine cholesterol check learned his visit had been coded as a “cardiac risk evaluation.” The insurer flagged him as having heart disease and raised his premiums the following year. In Illinois, a woman with abdominal pain was coded as possible ovarian cancer to justify a longer consult. That miscode led to a cascade of imaging and eventually unnecessary surgery, leaving her with permanent scars and debt. Tens of millions of patients each year experience denied claims or inflated bills tied to coding issues, billions of taxpayer dollars are lost in improper payments, and billions more are extracted from patients who never chose the risks they carry in their medical records.
The distortions engineered by the RUC can be traced across decades. In the 1990s cardiology societies secured high reimbursement for stent placements, and device makers thrived. Hospitals built catheterization labs, and thousands of patients underwent procedures later found to offer little benefit for stable disease. In the 2000s radiology societies, backed by hospitals and equipment vendors, pushed high reimbursement for MRI and CT scans. The country experienced an imaging boom, with patients subjected to unnecessary radiation and billions spent on low-value tests. In the 2010s prevention remained undervalued, while physicians under pressure turned to quick prescriptions. Opioids flourished in this environment, aggressively marketed by pharmaceutical firms, devastating communities, and killing hundreds of thousands. Each decade shows the same pattern: inflated codes fuel industry profits while undervalued prevention costs lives.
The human consequences of this design are vividly illustrated in the experience of Dr. Elisabeth Potter, a breast reconstruction surgeon in Austin. She went viral after describing how insurers interfered with care so aggressively that she was interrupted during surgery to justify a patient’s hospital stay. Her account revealed how reimbursement incentives empower insurers to override clinical judgment and delay treatment. After she spoke out, UnitedHealthcare excluded her new outpatient surgery center from its network. She had invested $4.8M of her own money to create a facility that could deliver high-quality, lower-cost care. By refusing coverage, the insurer forced her patients toward higher-priced hospitals and left many without access to reconstruction. Her punishment was not professional failure but speaking against the profit structures of insurers. Lawmakers with financial stakes in those same insurers remained silent, perpetuating the conditions that left both her patients and her practice vulnerable.
The ethical dilemma grows sharper when lawmakers’ financial interests are considered. More than a third of members of Congress have reported holdings in healthcare assets, with median values above $40K. Some sit on committees overseeing Medicare and Medicaid while holding shares in pharmaceutical firms, insurers, and hospital chains. Representative Chris Collins was convicted of insider trading tied to a biotech firm while serving in Congress. Representative Tom Malinowski traded up to $1M in medical and technology stocks during the COVID-19 pandemic and failed to disclose on time. Dr. Mehmet Oz, nominated to oversee Medicare and Medicaid, disclosed holdings in major pharmaceutical and insurance companies that stand to benefit from federal coverage decisions. In 2025, lawmakers accepted more than $50K in donations from top pharmaceutical firms while conducting hearings on drug prices. For constituents, the conflict is unavoidable. A vote to rebalance the code may protect lives but could cut into a lawmaker’s personal wealth. Inaction preserves both portfolio value and preventable harm.
The societies that dominate the RUC do not act alone. Orthopedic surgeons advocate for high-valued joint replacements, benefiting device makers. Cardiology groups push invasive procedures that fuel stent sales. Radiology societies defend inflated imaging codes that serve both hospitals and equipment vendors. Pharmaceutical companies benefit from undervalued prevention because poorly managed chronic disease guarantees more prescriptions. Each inflated code ripples outward, enriching corporate partners, hospitals, and lawmakers with investments tied to those firms. The secrecy of the RUC shields these connections. Its meetings are not public, its minutes are not transparent, and its members are not held to account.
This link between policy, profit, and politics reveals why reform has failed. Each postponement, each diluted bill, protects not only institutional stakeholders but also congressional investments. The harm falls on patients who face higher costs, misclassified records, reduced access to prevention, and increased risk of death from treatable conditions. Communities inherit shortages of family doctors, while insurers and device makers thrive. The cycle sustains a healthcare system where profit outranks people and where bending the code has become a survival strategy that leaves patients carrying risks they did not consent to.
The paradox is sharp. The code created predictability for insurers while producing preventable tragedy for patients. It brought order to billing while engineering chaos in care. It enriched a few while leaving millions without protection. It is a hidden law written not by elected representatives but by a private committee, sustained by congressional inaction, enforced by insurers, and financed through conflicts of interest that undermine the very idea of representation.
Food for thought:
What would it take to remove the power of the RUC from private hands and place it under independent oversight?
Should lawmakers be barred from holding stock in industries they regulate, especially when those industries profit from denying care?
Can a system built to reward crisis, tolerate bias, and excuse code switching ever be reshaped to value prevention, continuity, and dignity?
