Enshittification takes over healthcare service delivery systems
A colleague of mine pointed out to me and a group of colleagues on a list serv that I participate in for mental health professionals that the Macquarie Dictionary’s word of the year for 2024 is “enshittification.”
Enshittification is defined as “The gradual deterioration of a service or product brought about by a reduction in the quality of service provided, especially of an online platform, and as a consequence of profit-seeking.”
When I learned the term and its definition it was like a huge light bulb went off in my head and I experienced an epiphany. This is exactly what I have experienced in interacting with my health care system. So much crap. So much frustration. So much demoralization.
My doctor says “call me if you have further questions and concerns.” I don’t think he has any idea what a shit show the attempt to contact him is. After 15 minutes of listening to recorded robot messages and pushing buttons for selections on various phone trees, I finally get something that, maybe, is his office and then I get a recorded message that he is not available and to leave a message at which point the “mailbox is full” or the line goes dead. I think to myself “Well, fuck me. I’ll just die. I can’t take any more of this shit.” And then I ran across this term “enshittification’ which sums up my 15 minutes of anxiety, frustration, and torment in a nutshell.
I wonder what purpose all this automated messaging and phone trees and waiting on line and not arriving at the intended destination to convey the information accomplishes? Whose needs are being met? What would lead human beings managing health care services to design such convoluted and inefficient and ineffective systems? Money. It saves the system money putting the burden for communication onto the “consumer” of the service rather than the “provider.”
My more recent experience with the healthcare system was my inability to get my insulin prescription filled at my local CVS pharmacy which is understaffed, disorganized, overwhelmed and inept at dealing with problematic situations.
I got a text message from CVS which said that they could not meet my prescription request and to call my provider. So I did and went through the rigmarole I described above. When I finally got a hold of the med nurse, Bill, he said he didn’t understand what the problem at CVS was and asked ME what my dosage schedule was for the insulin which is on a sliding scale depending on my blood glucose levels. So I told him and he said he would provide that information to CVS and hopefully that would enable them to fill the script. Right? NO.
Now the problem seemed to be with my health insurance company who doesn’t want to fill the script because the type of insulin prescribed is not in their formulary. So I went into CVS and when I finally got the attention of the pharmacist after 10 minutes of waiting in line got some kind of bull shit that I couldn’t decipher other than I had to call my provider’s office back and have them reorder the insulin in line with what the insurance company is willing to pay for.
I lost my temper and said, “I just don’t understand who’s calling the shots here. Prescriptions now have to be electronically submitted by the provider to the pharmacy. I have no fucking control over that. And then the insurance company steps in and tells the provider and pharmacy what they can and can’t do. So now it's not just a three ring circus with the patient, the provider, and the pharmacy but a four ring circus with the insurance company calling the shots. How in this hell am I supposed to manage all this bull shit!” And then I said, which I regret, “No wonder Brian Thompson, got killed. And I wouldn’t do that but I understand the impulse, but maybe I should just kill myself.” The manager at that point walked over to the pharmacy and I left as frustrated and pissed as I have been in a decade. The whole situation is just so fucked up. And I once again think enshittification is a real thing and somebody is making millions and billions of dollars off of this screwed up service delivery model.
When I am upset and distressed, I turn to the Holy Spirit and ask for guidance on what I should do. And I always get an answer in one form or another. In this case, I am watching YouTube videos and this video pops up in my feed about CVS and PBMs, Pharmacy Benefit Managers. And I learned that the four ring circus is actually a five ring circus because health insurance company farms out their pharmacy benefit utilization to another party called a “pharmacy benefit manager” who develops the formulary and decides what medications will be covered and which won’t and what pharmacies they will reimburse and those they won’t.
And so the real culprit preventing my insulin prescription from being filled is the PBM working for my prescription plan which I bought as part D for my traditional medicare A and B.
I switched my pharmacies from CVS to Walmart. I finally got the script filled but the co-pay is $35.00 on a $120 bill which the Biden administration crowded about, bringing down the patient co-pay down to $35.00. The problem, though, is that the script that got filled is for a one week supply when I want a three month supply. Depending on the amount the script calls for would my co-pay still be $35? If so, then the smallest amount dispensed would be advantageous to the PBM and the health insurance company while it is very inconvenient for me having to have the script refilled weekly.
I learned 4 years ago in pre covid days that Walmart has their own over the counter insulin both short acting and long acting which is only $25.00 per vial. So it turns out that using the over the counter insulin is cheaper than using the scripts provided by my doctor to the pharmacy managed by my health insurance company’s PBM.
Are you still with me?
And so I am going off grid. I am going underground. I am opting out of the system as much as I can. The enshittification isn’t working for me. I am too old to be dealing with all the bull shit, though, age has nothing really to do with it. Nobody should have to deal with the enshittification which has become increasingly ubiquitous.
Cory Doctorow, who coined the term enshittification back in 2022, said that this enshittification process seems to go through stages: Doctorow wrote that this decay was a three-stage process.
“First, platforms are good to their users; then they abuse their users to make things better for their business customers; finally, they abuse those business customers to claw back all the value for themselves,” he wrote.
“It’s frustrating. It’s demoralizing. It’s even terrifying.”
After coining the term enshittification and the stages of its implementation in our social systems, he wrote later: Big tech can’t be fixed, he argues, but maybe it can be destroyed.
He adds a fourth stage to the tech platforms’ scatological journey from being good to users, to abusing them in favour of their customers, to abusing their customers to serve themselves.
“Then they die,” he wrote.
May they rest in peace.
It is extremely hard to change a system from within because like most systems they resist change and death. It is much easier to opt out of the system and find alternative ones or to engage with others in creating new ones.
Questions
Where and when have you encountered enshittification in your life and how have you dealt with it and how did it go?
To what extent have you dropped out of these systems and found other ways to get your needs met? Can you give an example?
What thoughts do you have about the stages of development that describe the enshittification process?
Yes! Just yes.