This is one of a collection of stories that are like “Final Destination” meets “The Monkey’s Paw” (W. W. Jacobs, 1902). As such, they are tragedies more than either mysteries or horror, and would appeal most to readers who enjoy the inexorable pull of a story arc that leads to doom. In each story, a protagonist makes a wish that comes true with fatal results for someone, often the person making the wish. Nothing supernatural, but just how things work out. (Or is it?) The technical details surrounding the fatal (or near-fatal) event are drawn from real cases in the US OSHA incident report database or similar sources and are therefore entirely realistic, even if seemingly outlandish. The plots draw lightly from cultural beliefs around actions such as pointing at someone with a stick or knife, wishing in front of a mirror, or stepping on a crack.

Tim was easily one of the 10 most despised people in the country, but out of millions of those people, a mere handful even knew his name. Tim worked as a manager for a health insurer and was the author of the preauthorization policies and the denial rules that physicians and patients hated most about healthcare. He didn’t actually delight in the frustration, anger, and despair that his work caused for hundreds of thousands of people. He saw their suffering as a mere externality, a regrettable side effect for which he was neither measured, nor for which he felt the slightest responsibility.

It would be tempting to imagine that Tim was a man of grotesque character and revolting habits, a slovenly couch potato who kicked dogs, picked his nose in the library, and double-dipped at parties. The fact was that, as an evil person, he was quite banal. He didn’t mind dogs, had very clean personal habits, loved a game of pickup basketball, and he very seldom attended parties of any description. His evil genius was that he was highly skilled at putting toxic ideas into executable instructions, and did so efficiently, effectively, and unobtrusively. He could interpret a horrific and half-articulated desire by senior management and turn it into a well-executed atrocity in a shorter time than sanity could prevail. He had expertly crafted onerous rules that allowed the insurance company to jettison members whose claims suggested increasing risk and the potential of forthcoming high costs. He meticulously sculpted a maze of escape clauses that allowed the insurer to rescind responsibility for burdensome conditions. His masterpiece, however, was his interpretation of the principles of utilization management that he wove into a steel net of preauthorization that reduced exposure, delayed payment, and solidified profit. It also drove clinicians insane.

One of his gems was a mechanism to limit the number of providers who could claim in any specific procedure. Using a combination of payout history, Medicare data, and re-identified data purchased from external data brokers, he could model the number of providers with AI for an array of procedures. For example, the simulations he ran showed that by limiting the number of clinicians they would reimburse for any one surgical procedure, they could bring the cost down. The simulation suggested that the risk for medical error and 30-day readmission inched up in tandem, but since the insurance reimbursed at a lower rate for readmissions, that was actually a benefit rather than an impediment in most situations. Tim adjusted the model to optimize savings for a set of abdominal surgeries. After several hours, Tim had a way to save several million dollars a year for the insurance company with an insignificant increase in externality costs. He typed up the business case and justification and submitted it for approval. Tim made a great many such adjustments to physician rankings in the member app and to which care centers appeared in the approved list.

Tim could swear that he actually heard something in his belly tear; he certainly felt it. He had leaped up to tap the basketball away from the hoop. Stretching as far as he could in a running jump, something in his belly tore. The pain was not as intense as he might have expected from something that sounded that bad, but he was definitely tender in an urgent sort of way, and his gingerly probing fingers encountered a bulge like a mushroom a few inches above his navel. Pressing his palm against it felt better, and the pain was not so demanding that he needed an ambulance. He wrapped a jumper around his middle, knotting the arms tightly over the protruding knob, and drove back to his apartment. The pain was certainly there, but after a hot bath, a couple of ibuprofen, and a whiskey, it receded as long as he was lying on his back and not walking around.

He slept fitfully, waking up in pain every time he turned, but managed to sleep until the alarm went off at 6 AM. Sitting up brought an urgent wave of pain, and Tim realized that this was not something that was going to fix itself. He found that he could stand and walk as long as he did so very carefully while pressing against the knob with a fist. Brushing his teeth was OK, but then he choked while gargling, and the coughing was met with excruciating pain in his belly. He could manage a very careful bowel movement, but it was clear that he needed medical attention. The insurance app on his phone suggested that he might have a hernia and that outpatient surgery was the recommended option. The free 24×7 tele-nurse provided by his medical insurance concurred and guided him through the app. He found the three highest-rated general surgeons close to him that were in network.

Dr. Murphy specialized in hernia repair. He preferred laparoscopic, but still performed traditional open surgery and was increasingly using a robotic approach. What he liked about the robotic systems was the 3D imaging. With the tremor filter and articulated instruments, he thought it allowed finer movement and maybe a longer career for a surgeon. It was starting to look to him like robotic surgery was superior to conventional laparoscopic surgery due to the improvements in visibility and manipulation. Compared with open repair, both options resulted in less blood loss, fewer perioperative complications, and shorter hospital stays. He did prefer having a physician assistant during surgery, but increasingly this was becoming an issue with some of the insurers. He had spent hours trying to argue the case and get preauthorization for a PA, but it was like arguing with a pot of glue: messy, infuriating, and ultimately a waste of time. In practice, it meant he could perform fewer pre-surgery checks and spend less time in pre-operative discussion with patients, but so far there had not been any issues.

Tim’s plans unraveled at 7:16. Unable to walk fully upright without pain, let alone get himself to the consultation, he called an in-network ambulance via his insurance app. The rules that he had authored routed him to the closest covered urgent care center because, while it was further away, it was cheaper than the hospital ED he would drive past. There was a small delay in care while the urgent care nurse realized that this was a surgery beyond the scope of the center and transferred Tim to the nearest in-network OR.

Dr. Murphy was used to schedule insertions to accommodate emergent cases, but they were always a bit unnerving. This one was a 43-year-old male with an incarcerated and possibly strangulated epigastric hernia following a basketball game. He looked over the patient details, but because the urgent care center used a different system, and the data sent across by the insurer was incomplete, there were some missing patches. He sighed and scrubbed up.

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The surgery was uneventful, but it was clear that Tim had arrived with absolutely zero time to spare, and there were hints that ischemia had started within the trapped tissue. Tim woke up well, and after a 3-hour observation as per his rules, he was discharged and took a cab home. He was amazed at how much it had all taken out of him; just walking up the front stairs and one flight to his apartment left him winded and breathless. He lay on the couch, snoozed for a few hours, and woke feeling cold. It felt like it took forever to get up to fetch himself a blanket, and he dithered about the kitchen feeling thirsty but not quite sure what to get. He eventually settled on orange juice and a few cookies, and was exhausted by the time he got back to the couch, only to realize after a minute that he had forgotten the blanket in the kitchen. Breathing like a steam train, Tim was propelled by the shivering to go fetch his blanket.

Tim slept fitfully and couldn’t fully wake up when the phone rang. He stared at his phone, not quite registering for a moment. It was the hospital calling with an automated customer satisfaction survey, and Tim tried to talk back to the voice, but eventually just hung up because it was too long and too confusing. He couldn’t shake feeling so cold, and even picking up a leg made him pant. He thought that he should maybe call someone but didn’t know who he wanted to call. He dozed off again instead.

Almost exactly 12 hours after calling the ambulance, Tim died quietly on his couch from the sepsis that had been blossoming rapidly in his body since his urgent care stay. He would never again pen another insurance rule.