The Price We Pay: What Broke American Health Care--and How to Fix It

by Marty Makary

Nudges from doctors can be as powerful as IV sedation. Sometimes we steer patients toward what’s best for them. Sometimes we steer patients toward what’s best for us.

Sometimes we steer patients toward what’s best for us.

we were saddened to see happy, grateful people, mostly African Americans, being fleeced by white physicians and their staff.

The idea of the medical industry intruding on Sunday worship brought to mind the biblical account of Jesus throwing the merchants out of the temple.

“Unless someone with expertise is honest with me, I don’t know what to believe.”

The politicians debated how to fund health care, but what we really need to talk about is how to fix health care.

If the politicians truly want to see why health care costs so much, perhaps they should suspend their arguments and take a field trip to the local churches. They would only have to travel two miles down the street.

Henri’s family was disturbed by the ethics of a hospital that would try to charge $150,000 for something they would do for $25,000. They didn’t expect a hospital to operate like a used car lot. Their trust had been shattered. I empathized with them. The hospital had tried to take advantage of them when they were vulnerable.

That’s the markup and discount game.

And many offered the simple explanation “We have to make up the cost of taking care of the uninsured.”

I learned that the secret discount that an insurance company gets ranges from 4 to 90%.

A hospital’s true costs are as mysterious as the curse of King Tut. There’s good reason for the fog—it’s lucrative.

I discovered categories of people who are explicitly and sternly told they must pay those inflated sticker prices.

Did anyone ever intend things to get this bad?

“The law allows us to charge whatever we want. If we want to charge a million dollars, she has to pay it.”

Health care has been one of the leading drivers of job growth in the United States, a trend that has made it the leading industry in the U.S. economy. But is this industry of new hires who are “playing the game” generating a product? Is this game making a meaningful contribution to our country’s GDP? Or is it a bubble?

When people wonder why health care costs so much in the United States, they must remember that the cost of the giant repricing industry is built into the cost of medical services. The question no one in the health care establishment has been asking is: Do we really need it?

Making real prices public would infuse much-needed competition into health care’s bloated $3.5 trillion market.

predatory billing practices are rare in the few health care sectors that have already adopted real price transparency, including cosmetic surgery, in vitro fertilization, and LASIK surgery.

The issue is not how many people will look at prices. It’s whether we as a country will empower proxy shoppers to drive value in health care.

We had gone into medicine to take care of the sick and injured, not to take advantage of them.

Insurance companies like having secret discounts and networks.

The self-preservation efforts of the stakeholders are so strong that California lawmakers had to pass a law to prevent insurance companies from retaliating against hospitals that disclose prices.

“What’s wrong with garnishing wages if someone doesn’t pay their debt?” she argued.

I explained that hospitals historically have been a safe haven for the sick but that aggressive billing was now eroding the public trust between the medical profession and the community, some whom now avoid care for fear of price gouging.

“When the rich rob people, their company pays a fine that doesn’t affect them,” a Midwestern farmer said. “If I rob someone, I go to jail,”

Some respondents saw hope in President Trump’s anti-establishment style, which helped me better understand how he swept elections.

Hospitals usually claim they can’t get by on what the government pays through Medicare or Medicaid. Columbus Community Hospital proved they could.

With big money on the table, it was off to the races.

While there are many social injustices in this world, the reason I’m so appalled at predatory medical billing is that it’s done to people when they are at their most vulnerable.

But when the company had no market participation, it could charge 766% of the market rate.

“Providers knew that if they failed to provide a competitive quote, the customer would contract with another service,” Frazier wrote to the investigators. “In other words, the quoted rates are the market prices for the above transports.”

“Air ambulance providers go to great lengths to conceal their billed charges, operating costs, and the availability of other providers,” Frazier wrote to investigators. “Again, the last thing they want to do is participate in a market.”

It may take an act of Congress to end kickbacks and institute patient protections in the air ambulance business. But state lawmakers could take immediate action to protect consumers. If they can’t control the prices, at the very least they could publicize them. How about a law requiring air ambulances to tell patients how much their flight is going to cost? Or a database that would track and publicly report each company’s charges per flight? The database could also name the person who made the decision to summon the air ambulance company, so that hidden conflicts of interest could be revealed. If patients are going to be taken for a ride, at least they have a right to know how much the ride will cost them.

But our methods of measuring quality are flawed. We focus on the results of a procedure, not on whether the procedure was appropriate.

In my opinion, the positive response to the “Dear Doctor” letters was because this program was 100% homegrown, based on the wisdom of practicing doctors who understood the proper use and misuse of their craft.

But why do some performance improvement programs work so well while others struggle? I attribute part of the success to civility. By including practicing doctors early and by using a peer-to-peer method of sharing data in a way that is nonpunitive and confidential, we were highly effective. Moreover, the project focused on what doctors believe to be important.

I’ve examined hundreds of quality metrics over the years and developed my own. I’ve come to believe many of them need context to be meaningful. The metrics must zero in on what it means for a patient’s quality of life and potential disability. The criteria should focus on significant harm or waste by extreme outliers rather than small variations in practice. The metric also must be measurable and designed so it can’t be tainted by bias or gaming. And finally, a sound metric should be highly actionable for the physician. Metrics such as mortality, while easy to collect, are hard to make actionable. We need more measures that provide direct insight into what the individual physicians can do right now to modify the way they practice.

Reference messy

No one in the broader medical policy world ever asked for their input, they explained. Yet again, I saw the disconnect between those making the rules in health care and those practicing it.

“This is amazing data.”

Unfortunately, some physicians believe that a lack of a randomized controlled trial means there’s no evidence. That sloppy and dangerous thinking gets worse when the medical community conflates “no evidence” with “not true.” That’s a logical fallacy.

When I asked why they do it so often, the GI docs responded with a comment I started hearing a lot: “It pays well.”

We laughed, but this was gallows humor, based on a shared recognition that our health care system was corrupt and we were all part of it.

He alone was milking millions of dollars from the system.

Susan raised a good point. She confronted me with a moral decision: Now that we can identify extreme outliers in the data, do we have a duty to let them know?

During and after our work to create procedure-specific guidelines, I watched the government and some insurance companies continue to issue draconian policies that limited opioid prescriptions to a 4-, 10- or 30-day supply. How could anyone dictate hard-and-fast limits when the amount of pain resulting from every procedure was different?

Most doctors worldwide reserve opioids for the classic indications—like terminal cancer, burns, and major surgery. I felt a bit ashamed, but it was true. The opioid crisis was unique to American medicine.

My experience taking Nexium reminded me how ingrained in our culture pill popping has become. The medicalization of ordinary life is so widespread it’s hard to avoid.

the traditionalists who designed my extensive medical education left out some of the most important parts of being a good doctor: effective communication and self-awareness.

the risks of medications and procedures are understated because of publication bias (a tendency to publish only good results) and the lack of studies evaluating long-term consequences.