The Hollow Men of Hims

>The real tragedy is not that Hims exists, but that it works so perfectly. Every day, thousands of people choose their compounded weight-loss drugs over FDA-approved alternatives, their combination ED pills over established single-ingredient treatments, their algorithmic consultations over actual medical care. They make these choices not because the products are better, but because the entire experience has been optimized to feel more like shopping and less like confronting the mortality and vulnerability that define the human condition.

Strongly disagree with almost everything in this article, but specifically this. The reason people make these choices is not because of slick marketing working against them, it's because the existing process to get medical treatment is paternalistic, hard to navigate and often expensive.

If you want safe and really high quality medical care you should absolutely have a personal physician you have a personal relationship with, who understands your lifestyle, your risk factors for side effects, and your medical needs deeply. How many Americans have that? Maybe a few dozen? The market has responded to just how terrible the existing system is.

It’s possible for both you and the article to be right.

The system sucks, but Hims are also terrible, and medical care should not be like Amazon prime.

One's a storefront. The other is a foundation of society.

These are not the same magnitude of sin, particularly since one's shortcomings are large reason for the existence of the other.

> and medical care should not be like Amazon prime.

Speak for yourself; that is exactly what I want. And anyone else who wants a similar experience should be able to purchase it.

I helped setup vaccination sites during the pandemic. One thing that struck me was how the providers who were working and the patients were all like “this is so much easier than normal medical care”.

Hims is like that.

But access to medical treatment, particularly drugs, should be "paternalistic", so I strongly agree.

> If you want safe and really high quality medical care you should absolutely have a personal physician you have a personal relationship with, who understands your lifestyle, your risk factors for side effects, and your medical needs deeply. How many Americans have that? Maybe a few dozen?

A bit of a tangent: I have this here in the US, through a model called Direct Primary Care. I pay $50/mo for a single provider, unlimited visits / communication, and highly discounted labs. She makes house calls on occasion. This doctor is working solely in my interest, and has little concern of insurance, except to help me navigate that system should I need a specialist, prior authorization, etc.

I do worry that it's sustainable, but I think there must by a way to scale up this practice of the general practitioner working in the interest of the patient.

My previous doctor was part of a large health system, who also happens to be directly associated with the large regional insurance provider whom my employer supplied to me without another choice. Every 8 minute visit centered around insurance and billing, with my health seeming to be a distant second. It seemed every visit had to end in some kind of prescription or referral, arrived at quickly and without much discussion. It quickly became clear they were not working in my interest, and I sought other options, eventually landing on the Direct Primary Care model. Now I have full 1 hour visits, and someone who seeks to understand what is happening for me completely, not through the lens of a payer.

That quiet literally is the paradigm for many countries. Get off a cruise ship in Latin America and walk to the nearest port side pharmacy and get almost anything you want.

This article is pure FUD pearl clutching

I don't think it will take more than 5 teenage overdose deaths to get most Americans to disagree.

It would only take that many for lobbyists to misrepresent the size of the problem and convince the public that it was a huge issue. Then they would enact regulations to widen the moat of legacy health care companies under the guise of "protecting the children".

Opposite those ODs you have thousands of people spending an arm and a leg on medicine that truly improves their lives, with no ill effect to them.

The way I see it, services like Hims are forcing a discussion that needs to have happened a long time ago. If people are willing to rely on them for medicines that can have some pretty serious side effects, what does that say about our existing system that people are eschewing? When you're asking people to choose between being able to afford to eat, and being able to afford something like insulin, why the fuck would you expect the decision making process to be anything otherwise?

Maybe many americans would disagree, right until the moment when they're nearly vomiting their guts out at the pharmacy, waiting for their zofran, which is going to cost them several hundred dollars, just because they're getting a version with a little glucose added so it doesn't taste as bad when you take it.

> I pay $50/mo for a single provider, unlimited visits / communication, and highly discounted labs. She makes house calls on occasion. This doctor is working solely in my interest, and has little concern of insurance, except to help me navigate that system should I need a specialist, prior authorization, etc.

Someone's presumably paying her more than $50/hr, which will burn through your monthly fees pretty quickly. Where's the money coming from?

$50 + health insurance? I saw my PCP after my health insurance had unknowingly lapsed and a physical was ~$1k with just some basic blood work.

Kind of tired of making life hard for everyone because a few stupid people might potentially make some bad decisions.

It works the same way that health insurance works -- most people don't need all that much care, and when time-consuming care is needed, it is often pushed to the specialists rather than the generalist. Your $50/mo payment might not seem like much, but if all you're doing is a bi-monthly checkin with them over the phone, you're really paying more like $100/visit for a 15-30 minute visit.

A lot of these 'concierge medicine' services are set up to deal with mostly people who don't need all that much medical care, beyond relatively brisk access to the doctor in a few rare circumstances. Since they also don't really do much in terms of specialty care, they tend to have fewer Px who need extensive personal care.

Personally, I am thankful that I have better options than going through hundreds of options with scant and unreliable information about which is actually effective and will be supplied as as claimed. If, however, that is your preference, you can certainly get it in the US, at almost any price point.

I’ve heard of this, also known as concierge medicine right?

But the figures I’ve seen quoted for such service usually begin in the four digits, sometimes five digits, annually.

Really? I wanted to try Cialis, primarily for my enlarged prostrate but also for the erection effects. I asked my primary care doctor, that was a $20 copayment, I fill it my local pharmacy and it costs about a $5 copayment for a month’s supply. It’s a big practice where I might have to wait a long time if I want to see the head doctor but if I don’t care who I see I can usually get in pretty quick and they do a good job of keeping notes so care is well coordinated.

Some of it is that there’s a general breakdown in trust that makes a lot of people think that somebody who shot a healthcare executive is a hero, or that there is little outrage that a lunatic like RFK jr is in charge of HHS. I mean, there are legitimate reasons to think institutions are illegitimate but I think there’s something self-perpetuating about distrust, people find meaning in it. It reminds me of the 1980s and 1990s when there were all the stories right out of Rambo that there were still POW in Vietnam and you’d see those black flags everywhere because it wasn’t patriotic enough to fly an American flag.

    > I do worry that it's sustainable

What is the maximum price that you are willing to pay?

Good for you but if you think your anecdote is the case for everyone you need to leave your personal bubble and talk to people

Literally the only reason I would use them is price. Cannot get anything for the prices they offer at a normal place or through insurance

I don't think it's all a bed of roses.

I suffered for 25 years from chronic pain that was referred TMJ. I've seen a cardiologist who is fine and all but much of his advice is the exact opposite of what I read on PubMed (and not just one paper on PubMed but 20 or 30 papers.) I've had several psych evals that I learned later were of very high quality for the their time but it took about 45 years for a book to practically jump into my hands at my university library which explained how I'm different from other people. I was annoyed as hell when a sports medicine doctor wrote NAD [1] on my chart when I was complaining about my activities being limited by knee trouble.

I work for a large employer in a state where it is illegal to offer junk insurance. My story was not too different when I was on Obamacare except I was paying what seemed an astronomical amount in premiums. I know a lot of people have it worse.

Looking at the how high the stakes are, I mean, you are all you've got, it's no wonder that people can't look at the limitations of the system with equanimity. The doctors I work accept me being a partner in understanding my conditions and my care but the moment they hear the voice of a professional fibromyalgia sufferer I bet they wish they could quit their job if they didn't have debt for student loans or to start their practice.

A lot of people seem to think "it would be allright if we just got more resources", I wish I could wave a magic wand and let them change places with Michael Jackson. Nobody is doing Elon Musk a favor shooting him up with Ketamine every week as well as other controlled substances. A lot of people just won't take help. I know people with schizophrenia who have no insight into their condition. Others with serious mental health diagnosis who refuse to take any med that isn't a controlled substance. For that matter, families where you get the kids a lot of nice and appropriate stuff for Christmas and you come back in a week and they've trashed all of it.

Having a positive attitude and just some gratitude for being here and the miracle that people have figured out as much they have and that a $10 prescription can cure conditions that were a death sentence just 100 years ago goes a long way. [2] I've personally tried to help a lot of poor people who seemed to have a bottomless pit inside them but if you look at the likes of Elon Musk, rich people can be like that too.

[1] https://www.quora.com/What-does-no-apparent-distress-mean-in...

[2] https://en.wikipedia.org/wiki/Serenity_Prayer

How could this possibly work out for her financially? To make 120k a year, she would have to be doing this with.. 200 patients; and I think the average GP makes a bit more than that in the US. That doesn't like a good bargain on her end.

I do not think I have ever spent more than an hour per visit actually in the room with my GP. I have an annual checkup. For a while there my GP was world class and also a blood relative.

200 patients at one hour per is a bit more than a month of 9-5s.

If I visited my GP once per 1.5 months I’d be paying a fuckload more than $50/mo in copayments alone, in addition to my incredible premiums.

Healthcare becomes pretty affordable when you’re not paying for actuaries and other scammers.

Not paying someone to chase insurance saves something anyway.

I'm at about 1 hour per year with my GP (I guess they can be spending additional time on notes or whatever, but I don't think it's much).

Studies have shown that patient satisfaction scores are highly correlated with whether the doctor writes a prescription. When patients leave with a prescription then they feel like they got their money's worth, regardless of whether they really need it.

Doctors make $20k a month or more.

That's 420+ patients at $50/m.

Doesn't seem feasible to know them all personally and deeply.

Other revenue would be needed.

200 patients is an extremely small panel size for the typical primary care provider in the United States. Many have several thousand.

a lot of actual conditions are actually treated with actual perscription drugs.

I want something like the Amazon Prime of healthcare, but the Amazon part is remarkably persistent: https://www.pbs.org/newshour/show/patient-safety-concerns-ar...

420 young, healthy patients probably see the doctor 2x a year at most. That's less than 20 visits a week for the doctor. And as soon as you become unhealthy you are passed along to a specialist or dropped.

You're paying for the bedside manner, not the medicine.

How people justify paying $1000 for probably less than 15 minutes of work is beyond me.

In the models I've seen, they still require and bill insurance. The monthly fee is a supplement for the doc practices.

Beause people don't want to die or be uncomfortable

Amazon Prime is facilitating prescription medications now.

You're not going to be seeing every patient every month. Many you might only be seeing a few times a year; They will have a quick phone chat every few months to make sure their prescriptions are up to date, maybe order a blood panel or two to stay on top of things. They're not coming in every week for an hour-long deeply-personalized appointment. As long as the practice limits itself to a reasonable number of patients, they should be plenty solvent.

We're talking about basic preventative care here. Your doctor doesn't need and probably doesn't want to be your friend for these sorts of things. There doesn't need to be a deep personal relationship there if it's not necessary.

(But also, $50/mo is a very low price. I've seen plenty of such services that are in the $500+/mo range. It's still way cheaper than health insurance would cost out of pocket, but it's not 'cheap' either.)

You're also probably fairly healthy and not much work. Concierge care for my elderly parents with complex diseases has been quoted at $20k/year.

> it's because the existing process to get medical treatment is paternalistic, hard to navigate and often expensive

I ended up paying over $1k out of pocket for two inconclusive sleep studies trying to get my sleep issue sorted out. I'm fortunate to work in technology where I can pay that sort of thing, but I still got zero results from my local medical community. I can't blame anyone for seeking self-treatment options. It can be pretty bad even with "good" insurance and the ability to cover co-insurance.

It is totally feasible and not uncommon for a family doctor to have 2000+ patients. Young healthy people can go years without interacting with the medical system, and when they do it's often some thing that barely involves their doc. I mean their doc doesn't know them personally then, but they have no problems worth surfacing clearly so why do they need to? The limiting factor really is the quantity of seniors and people with complex chronic conditions that you take on.

I guess I see this as somewhat different. These people are proactively choosing to maintain a relationship with a physician for an elective $50/month. I think the type of patient who wants a type of this relationship is the type who is going to solicit more than a single appointment per year; otherwise, why not just use what the current system gives us?

I could see something like this being useful for me; I'm constantly nagging my physician for different drugs I am triaging for a condition I'm dealing with. But, in that case, I wouldn't be the ideal patient for the physician. I wish this kind of thing could work, but I'm not sure how I see it working in practice, unless you move up market and charge more.

I’m 39 and I see my doctor once a year, at most. This year I had a urinary thing. Last year and the year before that I had a rash. The year before that I didn’t go. For all of my twenties I went three times. She still remembers me just fine, asking how is my CrossFit doing.

I see my wife’s doctor more often than my own because he is also our newborn son’s doctor.

They both have thousands of patients. The waiting rooms mostly have elderly, parents with their newborns and obese people.

Yea the US healthcare system is truly, truly awful, but that does not justify a turn to supplements, quackery, faith healers and witch doctors. The fact that people are turning towards these things should be a wake up call to the medical system, but then again the medical system misses wake up calls over and over…

Im sorry that has been your experience. I am too on a patient of a doctor who belongs to a "large health system/insurance system provided by my employer with no choice". I have never once discussed billing. Every visit, while short 10-15 minutes, is focused on my health and if I asked questions, can extend to 30+ or more... really depends on my questions. I have never needed an hour with a GP, maybe a specialist.

That included lab work, talking to the front desk people, the nurse who took the blood, the GP, the drivers, the janitors, the record-keepers, the lab techs, and the calibration work on equipment and who knows who else.

That is way, way more than 15 minutes of work.

I recently got a physical exam, including ultra sound, two urine samples, and bloodwork, at a private doctor in Austria and it cost 150€. You Americans are crazy.

I'm not sure how a physical would be more than 15 minutes of work. Lab techs? Standard blood tests are all automated, the most complicated part is putting the stickers on the vials. Yes, someone needs to calibrate the machine, but the machine processes 1000s of samples per day. I just checked, the price for a standard blood panel at a local lab is 14€. It's really not a complicated procedure.

Drivers? Janitors? What the hell are you paying those guys to justify a $1000 bill? And you really don't need to hire a driver to get a box of samples to the lab at the end of the day.

>there are legitimate reasons to think institutions are illegitimate but I think there’s something self-perpetuating about distrust, people find meaning in it.

The lack of institutional self-awareness is why it's not especially mental to find most humans more trustworthy than any institution. There's a bit of grandma's wisdom in not worrying about Kennedy or being a fan of Luigi.. then there are borderline cases like Shkreli or the CEO of UHC-- they seem to have the non-sentience of the upper-percentile institution (which btw includes almost every place of higher learning in the US, exceptions to be investigated for their unusual processes..)

I suspect the Ben Franklin thought of Congress as a bunch of his peers & not an institution (placeholder for one of PG's underworked cluster of ideas around informality)

And even if it didn’t treat something now, it can treat things later

For example, a lot of asymptomatic STDs get accidentally cured by people taking antibiotics for unrelated reasons. Less paternalistic countries let people buy very significant drugs over the counter.

Being able to rule out that a simple infection is viral instead of bacterial is a huge boon. Doctors who want to cry about risk of superbugs (while eating McDonald’s during their break) can shove their opinion alongside side their antibiotic doused meat slurry straight down their pie hole.

Every nice pain killer I get I keep for emergencies. You never know when you’ll actually hurt yourself and be very happy to have some extra Vicodin.

Paternialism in medicine has been destructive for the human race and it has led to a lot of very very negative outcomes.

Americans are so much more fat and unhealthy than aussies. That’s the primary reason why it’s so much cheaper in Australia.

I should clarify: the billing talk would come out when talking about options. “Let’s try X because insurance will need to see that we tried it before we try Y.” I don’t blame the provider. Navigating insurance still comes up with my direct primary care doc, but it’s not most of the visit. The real value I see is a willingness to take the whole picture into account (not just symptom -> med/specialist) and teach me about how things work and why. I have some complexity in my history for which this helps a lot.

Regarding the patient load discussion elsewhere, our entire family uses this doctor, we’re in for $200/mo but if we added up the interaction time even with me (a more complicated customer) it’s maybe 5 hours a year + some text communications with the MA / prescription wrangling. Their model seems to be all about effective scaling, I hope it is worth it for them, because my experience is vastly improved.

Ban insurance coverage for the quack bullshit like chiropractors, most forms of physical therapy , cupping, acupuncture, etc first.

If you’re not willing to do that than don’t try to take a holier than thou attitude against the supplement crowd. At least fish oil actually does help a tiny bit. Certainly more effective than 99.99% of adjustments.

Still not $1000 worth.

I’m not sure that’s true. The average BMI in the US isn't much higher than in Australia.

>She still remembers me just fine, asking how is my CrossFit doing.

That's because just before she walks in she reads your chart.

>what does that say about our existing system that people are eschewing?

"clearly we need to spend more on lobbying to get our ability to extract out pound of flesh more thoroughly written into the law"

-the system

Why not? It shouldn’t cost me $450 to go speak to my doctor for 5 minutes and say ‘I need Viagra’ and then have them write me a prescription, but it does cost $450 for me to do that. I can get (4) quarterly shipments from Hims for less than $450.

Personally I think viagra should be OTC, there’s no reason to gatekeep erectile dysfunction medicine.

The only thing they will "wake up" to is that they could be doing the same thing and probably make more money doing it.

+1000 to this. If your primary care physician works for a large medical chain (which most do), they aren't allowed to prescribe anything that goes against the chain's so-called "evidence-based" standards. Never mind that most medical chains also have insurance company arms and that these "standards" just happen to line up with whatever it is the insurance company thinks is appropriate to pay for. If you go to an independent clinic you can usually get prescriptions for "lifestyle" issues such as the ones Hims treats and then use GoodRx or a cheap online pharmacy to fulfill your prescriptions. Unfortunately, one of the side effects of the 2010 Affordable Care Act was to incentivize consolidation in the health care space, so independent clinics and practitioners are a dying breed.

I like the US healthcare system? At least my on-the-ground, lived experience into middle age has been great. I've always had high-deductible insurance through my employer, never had a problem getting a specialist (even during the supposedly horrible HMO years) or special service, eg. MRI.

With an HSA, I'm basically self-insured for everything short of something catastrophic.

I don't know if I'm an outlier in this American Carnage, but with very few exceptions, this is the norm in my circles.

I've anecdotally done some research and in SoCal a true concierge medicine for what I would be looking for with a brick-and-mortar location and imaging on-site is ~$5000/yr.

> you should absolutely have a personal physician you have a personal relationship with

best we can do here is the closest walk in clinic that isn’t fully booked by 9am and a doctor I’ve never met before. All they ever do is send me for blood work which is always flawless. Eventually my issues resolve themselves. If I get cancer or something serious I expect to just find out shortly before I die

Supposedly in the Salzburg airport in Austria, there's an information counter for people who have learned that they are in fact in Austria, not Australia...

I admit I went to Hims a while ago. I filled out the questionnaire and had a "physican interview" where I was literally told "You need to change this answer from this to that, and this answer to this" if I wanted to get medicine, and "would [I] like a chance to review my questionnaires and we could discuss again in a few minutes?"

That's not medical care.

Hahaha I just saw! They're two letters apart!

That's what you want until you have a serious and expensive health care problem. Segmenting off the healthy people like this simply means the people with chronic conditions or acute catastrophes are bearing more of the cost rather than pooling the risk.

Everyone wants to be the sickest person in whatever health care pool they are in, but that's not sustainable

Same. For relatively safe medications, people should have the freedom to get medications that will resolve their issues without jumping through a bunch of hoops. As long as companies are providing full disclosure on the medications they are providing and side effects, I don't see any issue with it.

This kind of thing heavily depends on your doctor and insurance plan. A lot of plans won't cover things like ED meds, weight loss, or hormone therapy. TBH I'm not entirely sure that's a bad thing as long as affordable alternatives are available outside of the insurance plan. Plans covering every little thing will increase premiums, so maybe for the products that Hims sells, this is a case of the market solving a problem.

I don't understand US medical schools in the least. My son is interested in medicine, and I have sat through presentations where the admissions officers describe how they pick the student that has the best sob story from dozens of overqualified candidates. Then the poor jerk that is selected will work 20hr days out of med school in residency and finally patients will wait weeks to months to see them because there are not enough physicians (or they will see someone with a foreign degree). How does any of that make sense? Why not admit a couple more kids, stop causing overtired residents to make mistakes and address the shortage?

Unfortunately, the AMA is a cartel of doctors that lobbies to put limits on government-funded residency slots to keep salaries high. [1]

1. https://petrieflom.law.harvard.edu/2022/03/15/ama-scope-of-p...

Americans can order their own lab tests for pretty cheap as well. In regards to pricing, the overhead for billing is about 1/3rd of the price, though not relevant in the poster's situation. It is part of why some prices here are so inflated though.

If a patient goes to see their doctor at a major hospital, part of that bill goes to pay for uninsured patients in the ER. Hospitals in the US by law have to treat everyone who come to the emergency room, which results in a lot of losses for hospitals that they have to make up for by charging higher prices on other services.

> And you really don't need to hire a driver to get a box of samples to the lab at the end of the day.

Smaller doctor's offices do their labs offsite, in the US just a couple of companies do the majority of blood work, as part of the contract with the lab, a driver comes by and picks up samples. In the great name of outsourcing, I imagine this driver works for a separate company as well, so now there is 2x outsourcing overhead, once for the lab, and again for the transport company. For doctor's offices that cannot justify their own lab, this makes some sense.

FWIW in my city at least, the majority of doctors are affiliated with large hospitals. They either work in a large hospital, in a satellite campus, or have an affiliate relationship (which from what I can tell just means medical records are automatically transferred over).

I go to a "smaller" office, it is a 3 story campus that is the satellite office of a huge hospital nearby. They do some of their own lab work and outsource other stuff. The hospital network is publicly owned and accordingly much nicer to deal with than many of the horror stories I hear online and from friends. (also the prices are reasonable and they always give me a price sheet up front of what everything will cost, which isn't always the case for some doctors...)

> I just checked, the price for a standard blood panel at a local lab is 14€. It's really not a complicated procedure.

Is that a 100% unsubsidized price?

In the US, cash price for a Comprehensive metabolic panel (CMP) is just $50. The same labs that the hospitals outsource to actually offer direct to consumer tests at really reasonable rates.

I just checked my hospitals cash rates:

A yearly checkup for an existing patient is $48.

Lab work is $48 (a $2 discount!)

Urine tests are another $20.

So in summary, OP got ripped off by their doctor's office.

Well I didn't know until I got sent a bill.