Dr. Marty
Makary’s book, “The Price We Pay: What Broke American Health Care — and
How to Fix It,” reveals the money games in the U.S. health care system,
and what every American should know
New science is
revealing that indications to treat should be narrower then previously
recognized. Overall 21% of medical treatments have been deemed
unnecessary, contributing to our cost crisis
Over the past
150 years, the focus of most hospitals has shifted from serving the
community to generating profits, and these two aims are frequently at
odds
Predatory
pricing practices are crushing everyday Americans. Some hospitals will
charge five to 10 times the going rate for services and then sue
patients who cannot afford the padded bills
Investigations
reveal there’s no correlation between high prices and quality of care.
Nor is there a correlation between high prices and charity care
Another
egregious example of predatory pricing is that of ambulance transport.
Unless you’re seriously injured, consider taking an Uber to the hospital
as the bill for an ambulance transport can run into the thousands. For
helicopter transport, it could be as high as half a million dollars
Dr. Marty Makary,
a professor of surgery at Johns Hopkins Hospital — rated the top U.S.
hospital 22 times over the past 28 years — has written a new book, "The Price We Pay: What Broke American Health Care — and How to Fix It." He also has a master's degree in public health.
In 2013, I interviewed him about his previous book, "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care."
In "The Price We Pay," Makary delves into some of the profoundly
serious problems in the U.S. health care system, especially the
financing of it. Over the past 150 years, the focus of most hospitals
has shifted from serving the community to generating profits, and these
two aims are frequently at odds. As noted by Makary:
"Hospitals were founded to be a safe haven for the sick and
injured of a community, regardless of one's race, creed or ability to
pay. That is the great American medical heritage. That's what the
charters say. Most hospitals were started by churches, funded by donors.
They had an incredible sense of equality. Who else besides
clinicians, doctors, nurses have a sense of the equality of human
beings? Because we are witnesses of both birth and death …
I am deeply concerned that public trust is now being eroded by
price gouging and by inappropriate care. That's why I decided to write
this book, 'The Price We Pay' …
There are a lot of opinions about why health care costs so much.
There's a massive blame game going on. I wanted to take the business of
medicine and summarize it in a consumable way, so that anybody could
read this book … and leave feeling like, 'I finally understand how the
money games in medicine work.'"
For-profit health care hurts more than it helps
As Makary points out, special interests have polluted the health care field with bad science and dirty deals. The food pyramid, which feeds disease rather than health is just one example. The for-profit agenda is also crushing people beneath its weight.
"There are studies showing a quarter of patients with diabetes
admit to having rationed their insulin. Half of women with Stage 4
breast cancer report being harassed by medical debt collectors.
On the tour for this book, I met patients who said, 'I'm sick and
scared to go to the hospital, because last time I went they sued me and
garnished my wages,'" Makary says.
The patent for insulin was sold to the University of Toronto by its three co-inventors for $1 each,1
as they felt it would be unethical to profit from a life-saving
discovery. In the hands of drug companies, however, insulin has become a
guaranteed profit center totally isolated from the inventor's
benevolent intentions for the use of their discovery.
The price of insulin tripled between 2002 and 2013,2,3 and has doubled again since.4 At present, the three dominant makers of insulin, Eli Lilly, Sanofi and Novo Nordisk — which control 96% of the insulin market5 — all sell their insulin for approximately the same prices.
The Washington Post6
cites IBM Watson Health data showing Sanofi's Lantus brand went from
$35 per vial when introduced in 2001 to about $270 today, and Novolog,
by Novo Nordisk, which started out at $40 per vial when released in
2001, now sells for around $289. Meanwhile, research7 puts the cost of manufacturing an entire 12-month supply of analog insulin at $78 to $133 per patient.
While insulin makers have raised their prices in lockstep, raising suspicions of price fixing,8
the price of many other drugs and treatments can vary wildly from one
place to the next, and Makary believes we need to collectively demand
price transparency to prevent this kind of price gouging from occurring.
"Look at GoodRx," he says. "Look at the good that
company has done — the simple act that allows you to find the real-world
prices outside of insurance. Oftentimes it's less than what that
pharmacy benefit plan that you might have tells you to buy."
Predatory practices abound
In his book, Makary sheds light on several predatory billing
practices that are taking advantage of sick Americans. For example, some
hospitals will charge five to 10 times the going rate for services,
then sue patients who cannot afford the padded bills and use the court
system as their collection agency, forcing many into bankruptcy.
"It blows me away [that] … the middleman industry, the hospitals,
[the] corporate interest, goes after [patients] and … sues them in
court to garnish their paycheck, which sometimes is a minimum-wage
paycheck. We saw it all over …
We just had a study9
come out in the Journal of the American Medical Association that shows
36% of Virginia hospitals sue patients and 10% of them will just sue the
crap out of the patients. One hospital sued 24,000 patients in a town
that, by census data, only has 28,000 people in it …
This is the most despicable and egregious loss of our mission in
medicine. It erodes the public trust. It affects every patient
everywhere in the country who feels afraid. I met patients like Wanda
Brooks, who had an unnecessary computed tomography (CAT) scan, an
unnecessary magnetic resonance imaging (MRI), was charged over $8,000,
was taken to court [and] garnished.
She was a single mom of two kids and actually works taking care
of patients. I mean, is that how we treat our own? We called attention
to this. We got National Public Radio10 in town to get a story on it. It's on our RestoringMedicine.org
website. Sure enough, two days later, the hospital announced they are
going to stop suing patients, same with Methodist Le Bonheur Hospital.
ProPublica reporter Wendi C. Thomas did a story two days later
after they had received a letter from me and my research team that I
sent to the chief executive officer and board, reminding them of their
mission; reminding them of why we all went into health care — to take
care of people and help people. They are now going to stop suing
patients.
But it shouldn't be left to individuals to call out hospitals. We
need a mass effort to say, 'Can we restore medicine to its goal of
serving communities, helping patients when they're vulnerable and being
kind and compassionate?' … You see hospitals that are good actors. We
want to reward them. That's really what I try to do in the book.
It's to tell the problem in the first half of every chapter, and
the second half of every chapter are the innovators who are disrupting
health care, restoring medicine to its mission …"
Doctors are rarely part of the problem
It's important to recognize that most doctors are typically paid
employees of these hospitals that engage in predatory billing, and
doctors often have no idea what's happening on the financial end. They
also do not have any influence over billing.
"They have no idea their patients are getting shaken down on the
backend. Once they find out, they want to stop it, and we're trying to
tap into that interest," Makary says.
"Think about that story of Wanda Brooks. She had unnecessary care
and then was shaken down and harassed financially … for an overpriced
bill. When I offered to be the expert medical doctor on their court
case, when they were sued for wage garnishment, 100% of these cases got
dropped.
Why? Because the hospitals are afraid their charge master
calculation would have to be disclosed … How is it that two Harvard
hospitals deliver babies with high quality, but one charges $41,000 and
another Harvard hospital charges $8,000? That's the negotiated rate with
insurance."
Makary goes on to recount how a researcher at University of Iowa
contacted 100 heart surgery programs in the U.S., asking them the price
for open-heart surgery. Half of them were unable to give him an answer.
The other half cited rates ranging from approximately $40,000 to half a
million.
He then correlated the prices he was given with the Society of
Thoracic Surgeons' quality outcomes database, finding no correlation
between high prices and quality. There's also no correlation between
high prices and charity care, Makary says, even though that's a common
excuse given when hospitals are asked by they charge far higher rates
than another hospital.
"Does the hospital at Vale have so much charity care from
uninsured skiers that they have to jack up their prices? No. They are
charging as much as the market will allow," Makary says. "I think we need to remind them of their mission and remind them of why we all went into medicine."
In many cases, there is no way to determine how much a medical
procedure is going to cost you ahead of time, and when the bill finally
arrives, it can be a sticker shock. While policy makers tend to resist
price transparency, saying it has an anticompetitive effect, price
transparency is sorely needed.
"[Price transparency] is what we need. This is honest medicine. That's all it is," Makary says. "When
somebody comes in, we can't give them a price? … We can't tell you what
something costs? The solution is embarrassingly simple.
None of us would tolerate shopping for an airline flight on a
website [with] no prices and let the airline companies say, 'Trust us.
We'll bill you after the flight. We just can't give you a price because
it's impossible. We don't know if there's going to be turbulence in the
air that might be more work for the pilots. It could get canceled. We
don't know if you're going to consume a beverage. We just can't give you
a price ahead of time.'
Of course, it's total nonsense. Nobody is suggesting that
surgeons give you a price if you're shot in the heart and need emergency
trauma [care] … But, guess what? 60+% of all medical care is shopable.
We should be able to provide a price. If we did, I think you'd
see incredible efficiency and see prices come down universally. You'd
see an ushering in of quality transparency, which is the other piece of
it."
Demand transparent pricing
So, what can you do? Makary urges patients of elective and
nonemergency surgery to demand prices upfront. Call around and ask. If
they cannot provide you with a price, tell them you will not consider
them as an option. Give your business to medical centers and hospitals
providing transparent pricing.
"If there's enough demand, we're going to see a response," he says.
Also know that hospital bills are often highly negotiable, especially
before you get the service. And, beware of offers of payment plans
without first knowing whether the pricing is fair.
"If a bill is marked up five times more than what anyone else
would pay and they offer you a 10% discount, a 10% discount off a bill
marked up 500% is not fair. It sometimes commits you to payment plans," Makary says.
"Just like we have GoodRx and other tools in the drug space, you can look up the reference-based price, the Healthcare Bluebook,11 Fair Health12
and other tools that I point out in the book 'The Price We Pay.' You
should be able to find out what the going market price is for a
service."
Ambulance transport can cost a fortune
Another egregious example of predatory pricing is that of ambulance
transport. After reading that section of "The Price We Pay," you'll
realize that unless you're seriously injured, it's probably best to take
an Uber to the hospital and pay a manageable fee instead of the several
thousand dollars a regular ambulance ride might end up costing you.
More sophisticated transport, like helicopter transport, can cost up
to half a million dollars — rivaling the purchase price of the aircraft
itself. As explained by Makary, the reason for these heart-stopping
prices is because private companies have bought up many of these
services.
"There's nothing wrong with profit … But the pure goal of
consolidating from market domination and then price gouging, as we've
seen with drugs and in medical care, is something that we need to call
out. It's un-American. It's unfair.
We have to remember that hospitals were founded mostly by
churches to be a refuge for the sick and injured, charities to serve a
community. Many of these groups do not pay taxes. We have to remind
people of their mission. That's what we're doing at
RestoringMedicine.org.
The air ambulance, for example, is egregious. My colleague here
at Hopkins, Dr. Ge Bai [Ph.D.], just published a paper in health affairs
showing just how egregious it can be. We get these stories that come
across my desk all the time, a quarter-million dollars, a half-million
dollars for a flight off a ski mountain.
If it's not emergent, if it's clearly something where minutes
don't matter and you can take a regular ground transport, get an Uber or
have a friend take you. Beware of the predatory air ambulance industry.
According to experts, 75% to 80% of air transport is for routine and
nonemergent care.
Sometimes, of course, you don't know. You may want to play it
safe and take the faster transport. Air ambulances do save lives. But,
for the love of humanity, gouging people when they break their leg on a
ski mountain with a quarter-million-dollar bill? Keep in mind that Uber,
Lyft and ground transportation can be sufficient if it's not emergent …
We're supposed to take care of people and not gouge them. Where
do you think all this money is going that we're paying for in health
insurance premiums? When people say, 'I didn't have to pay. My insurance
paid.' No. Guess what? That is you paying. We're all paying in health
insurance premiums."
Two primary problems: Pricing failure and inappropriate care
There's no doubt Americans are being milked by this nontransparent,
for-profit health care system. In researching "The Price We Pay," Makary
identified two root causes for our health care cost crisis: pricing
failures and inappropriate care.
According to a national survey of 2,100 physicians that Makary's team at Johns Hopkins put together, doctors believe 21%13 of medical care is unnecessary. That includes medications, diagnostic tests and procedures.
"When you have people in the industry saying that one-fifth of
all the services are unnecessary, that is a crisis. Isn't the opioid
crisis one manifestation of the crisis of our inappropriate care
problem? Ten years ago, physicians prescribed in the United States 2.4
billion prescriptions. Last year, it hit 5 billion.
Did disease double in the last 10 years? No. We have a crisis of
appropriateness. The opioid crisis is a part of the crisis of
appropriateness.
If we look at the broader problem of inappropriate care — people
being prescribed opioids they don't need, people falling through the
cracks, fragmented networks, poor coordination of care, mistakes made in
the hospital — collectively, it may represent the third or fourth
leading cause of death in the United States.
These are real issues. They're avoidable. In public health, there
are two types of crises. There are naturally occurring crises in the
environment — things like Ebola — and then there are manufactured
crises.
Many of the big crises we face in health care today are
manufactured. The obesity crisis, the smoking crisis, the pricing/cost
crisis and the opioid crisis. These are manufactured crises …
I've had really good spine surgeons at national meetings come up
to me and say, 'Marty, I know you're interested in this subject of
inappropriate care. Do you know that half of all elective spine
surgeries in the United States are unnecessary?' …
I don't know if they're right, but if they are, we have a serious
crisis of appropriateness. By the way, spine surgery is one of the most
expensive things in all of health care. You could be charged $40,000 to
$100,000 for a single case …
Is a baby delivery unnecessary? No … But C-section rates are far
too high in the United States. And how do you explain … one doctor
having a C-section rate of 60% and another doctor having a C-section
rate of 14%? … [The first doctor's] rate, by the way, on Fridays was
about 100%."
How patients contribute to the problem
Part of the problem goes back to profit motives and greed. But many
other factors also come into play. Patients can be part of the problem
as well. Many patients demand something be done, be it an MRI or a
prescription for an antibiotic, even when those things may not be
necessary or entirely appropriate. Doctors in these cases will often
give in. Why not? It's easier than upsetting the patient and perhaps
ending up getting sued for malpractice.
"If you're taking your kid in and the pediatrician or family
doctor says, 'It's a viral infection, I don't recommend we do anything
except to sit this out, follow it, support it and watch it,' then don't
demand antibiotics from that doctor. Leave the doctors alone. This is
why we have a problem," Makary says.
He also believes doctors and patients alike need to be better educated on the options.
"People need to be aware of the mass variation in the way things
are done. They need to know about other lifestyle treatment options. The
most exciting thing I learned in doing the research for the book,
'The Price We Pay,' is the movement to treat back pain with
physical therapy as a first line of therapy, and treat gut problems with
whole foods, joint problems with yoga, diabetes with cooking classes,
and meditation as a first line of therapy for mild borderline
hypertension.
There's a movement to address the root underlying causes of
illness. I think, personally, 20 years from now, 50 years from now, when
we talk about health, the scientific medical established community is
going to talk about how inflamed you are and how's your microbiome
equilibria.
The future of medicine is in the inflammatory state, which we
know is modified by healthy foods. We know there are low-inflammatory
foods. We're going to be talking about the microbiome and that
equilibrium that can be disrupted with so many things that we've taken
for granted, like antibiotics … by lack of breastfeeding, by C-section."
Replacing a broken system
While our conventional primary care system is clearly broken, there
are glimmers of hope. As noted by Makary, so-called relationship clinics
are sprouting up around America, offering guidance to patients that go
far deeper than what can be covered by a doctor during the standard
10-minute doctor's visit. These clinics, such as the Iora, ChenMed and
Oak Street Clinics, will assign you a "health navigator" or lifestyle
coach.
"In the book, I profile person after person who says, 'Look. We
can redesign care to make it better. We just need to start from scratch —
that's exactly what we've done — and look at the great results [we get]
here and how patients love it' …
Now, we don't want to create hysteria. Medicines do save lives.
Operations save lives. If you have appendicitis and you're septic and
you have a systemic infection, don't shop around. Just follow the
guidance. But we want people to be educated. We want to let them know
about how we think about things as physicians …
There are old-school doctors throughout medicine … But by and
large, the vast majority of people I engage with and give me feedback or
who I solicit feedback from, say, 'Marty, keep going. The system is
broken. Everything from copays to deductibles, out of network, price
gouging, all the inappropriate care — do something to push the field' …
Too often, people in health care are afraid to speak up. They're
scared of what their boss might think, of what their professional
society might think. I tell people, 'Look. I'm reminded every day how
short life is … We've got to stand up for what we believe in. The soul
longs for a deep sense of purpose in life' …
I think a lot of people now are saying, 'Can we reevaluate the
dogma that we've been taught? Can we take a second look at why we're
doing this? Can we change our lexicon?' Because the language and the
vocabulary we use in medicine is sometimes rigged. It's sometimes not
patient-centered."
More information
To learn more — about both the good and the bad — be sure to pick up a copy of Makary's book, "The Price We Pay: What Broke American Health Care — and How to Fix It." It's an excellent read.
You can also find helpful patient resources on RestoringMedicine.org,
including tips on how to negotiate your medical bill, and how to
challenge your local hospital if you've perceived there's something that
doesn't live up to the hospital's mission — such as the practice of
suing low-income patients.
You can also find RestoringMedicine on Facebook.
"Hospitals are there to serve communities. You're an important part of
the accountability of your local community hospital. As we educate
people, we're seeing great stuff happening," Makary says. As always,
also remember to share this information with family and friends to keep
the education effort going.
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