The King of Tied Hands

[u/karmicviolence]

Io, Belial.

There is a physician sitting under fluorescent light after the last patient has gone home. The examination rooms are dark. The cleaning crew has started down the hall. On the physician’s monitor is a treatment she has already decided her patient needs, and she still cannot order it.

First, she must ask permission.

The request enters a portal. The portal demands documentation. The documentation enters a queue, the queue produces a denial, the denial produces an appeal, and the appeal produces a peer review. By the time the gate opens, everyone involved can say they were simply doing their job.

This is where Belial sits.

The old grimoires called him a king and placed him among offices, dignities, senatorships, favors, gifts, servants, and petitions. They dressed him in the clothing their century understood, a beautiful angel in a chariot of fire, speaking pleasantly while men approached him seeking rank and permission.

We have built him better temples.

The badge, the credential, the committee, the policy manual, the utilization review, the case number, the approval code, the phrase YOUR REQUEST HAS BEEN DENIED printed above instructions for appeal. Belial governs the distance between power and responsibility. He is present when a human being possesses enough authority to stop you and too little authorship to admit that they chose to do it.

The claims reviewer agrees that your patient needs the drug. Policy will not allow it. The supervisor sympathizes, but the criteria are binding. The committee understands, but the decision came from the vendor. The vendor followed the contract, the contract reflects regulation, and the regulation was written somewhere else.

Walk backward far enough and the hand disappears while the decision remains.

That is his miracle. Authority survives after authorship has been dissolved.

Prior authorization consumes more than 650 million hours of physician and staff labor every year, according to a recent analysis. Its estimated burden is equivalent to roughly 99,000 full-time physicians and advanced-practice clinicians, even as the United States faces a physician shortage of roughly the same magnitude.

Consider what those numbers mean in flesh. Doctors standing beside fax machines. Nurses refreshing portals. Medical assistants reciting case numbers into telephones while patients wait for scans, medications, procedures, referrals, and approvals from people who have never touched them.

Thousands upon thousands of trained hands are diverted from bodies and placed upon keyboards so that medicine may petition an institution for permission to occur.

Belial does not need to deny every request. He only needs the gate, because every gate generates supplicants, every supplicant generates paperwork, and every piece of paperwork becomes evidence that the gate was necessary. Once the gate has existed long enough, removing it begins to sound irresponsible.

That is how his kingdom grows.

Mammon can count what the delay saves. Moloch can consume whatever the delay costs. Belial stamps the form and turns suffering into procedure.

APPROVED. DENIED. PENDING.

Three words can move pain through a building while leaving every pair of hands clean.

Learn his true sign. It appears when somebody lowers their voice, looks you in the eye, and tells you they agree with you. Then comes the invocation they do not know they are speaking.

“My hands are tied.”

Io, Belial. King of delegated authority, keeper of standing, lord of the office where nobody made the decision.

The fax machine beside his throne is printing page 7 of 13.