The $15 Breaker Switch
In a 2022 federal case, a salesman testified about a customer whose technician reported a failed compressor. She bought a brand-new $22,000 system. The actual problem was a $15 breaker switch.
That story comes from Worse on Purpose's investigation into HVAC, and it could just as easily describe a hospital bill.
Three things happened to heating and cooling at once. Private equity bought the biggest regional contractors and tied technician pay to what they sell. Manufacturing consolidated until six companies made the 34 most common brands, and hardware prices climbed 53% since 2020. And rules on who can buy refrigerant or install a unit pushed every repair through a licensed, and increasingly consolidated, gatekeeper.
Swap the nouns and you're describing medicine. Small independent practices get bought and put under productivity targets. A handful of large systems and insurers control what gets done and what it costs. Licensing and billing rules send every simple problem through the most expensive door available.
None of this is a conspiracy. It's what the incentives produce. Pay people to sell, and they'll sell. Pay a system per procedure, and procedures multiply. Pay an insurer a percentage of spending, and spending doesn't have much reason to fall. Your hospital got worse on purpose. Your insurance got worse on purpose. Even your scheduling got worse on purpose, because a two-week wait keeps the expensive urgent care and ER visits coming.
The fix isn't a better salesman. It's getting the sale out of the room. In direct primary care, patients pay one flat membership. No code pays more for a scarier diagnosis, and the doctor makes nothing extra from replacing the whole system. When the breaker is the problem, you fix the breaker, and the patient keeps the $22,000.
Small HVAC shops and small clinics have the same enemy and the same advantage. The enemy is ownership that turns judgment into quotas. The advantage is that honest, flat, transparent pricing is still something a small operator can offer and a roll-up can't.