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

by Marty Makary

For people wondering why insurance premiums are going up, one of the leading drivers is the doubling of prescription medications our country has witnessed over the last decade.

45% of Washington State health care services were unnecessary. In total, they found that 600,000 patients in Washington underwent medical services they didn’t need, costing an estimated $282 million in one year.6 Topping the list were frequent screenings and tests deemed irrelevant to care, such as unnecessary lab tests routinely performed before minor surgery.

For years, health care reform in Washington, D.C., has asked the question: How do we pay for health care? But the real question is: How do we fix the health care system? Addressing the epidemic of too much medical care (which doctors believe represents 21% of all medical care delivered) is a practical solution.9 My own medical experiences have reminded me that the problem is not just administrative waste, it’s clinical waste as well that’s driving up health care costs for everyone.

As we address the challenges of global public health, we should remember that it’s not just too little care that is the problem. In some areas, the problem is also too much medical care.

The appropriateness in medicine problem exists in the United States but may be many times worse in some of the poor countries I visited.

Walking into a car dealership puts a knot in the pit of my stomach. I feel cheapened by the whole experience. I know that I will have to haggle with the salesperson, as the sticker price is never the real price. I will endure the silly playacting (“Let me see what my manager can do”). Even if I walk out with a good deal, I leave feeling ambushed, frazzled.

Tesla has created an experience centered on the customer, rather than sticking with a system entrenched in outmoded practices.

Tesla’s market cap surpassed that of Ford. All the while, do you know how much money Tesla has spent on advertising? Nothing. Zero dollars. Tesla has won people over with their intense focus on the consumer—a strategy common to disrupters of entrenched billion-dollar industries.

Why does our health care system treat ordinary people like criminals when they are out-of-network?

Health care doesn’t have to be so different from any other business in America. Imagine you see an orange in the supermarket with no price on it. You take it to the register to get a price check. “How much for the orange?” “You have to buy it to find out,” the cashier says.

Employers that partner with Healthcare Bluebook are able to flag the price gougers in the market to their employees and point them to a fair-priced provider. Jeffrey and his team categorize every medical center and doctor in an employer’s area based on their markups. Each medical facility gets a rank of green, yellow, or red, rated on prices and a composite quality score.

We need to see prices, so patients and health plans can determine which facilities are operating in a way that’s efficient, and which are just trying to maximize their profit.

It’s my hope that these disrupters and others will make markets rational and efficient rather than secretive and predatory.

“Don’t blow smoke up my ass,” he erupted. “My wife can’t even afford her multiple sclerosis medication and you come up here in your limo! We’re struggling, and all you people are getting rich off of us.”

He began recommending health insurance options based on what was the best value for employers, rather than the ones that paid him the most.

Phil and his colleagues got me up to speed fast as we sipped piña coladas in the Florida heat.

Isn't painting himself well here either

“The way brokers are paid is one reason people are paying too much for health insurance, and I can’t believe no one is talking about it.”

They were not bad people. They are just responding rationally to market forces.

You might do whatever it takes to maintain the status quo.

Not a good sentence.

Employers should be able to see how brokers, insurance companies, pharmacy benefit managers, and providers are being paid.

But market forces can also be a powerful change agent.

Gagging a health professional violates everything that sets medicine apart as a noble profession. It compromises our heritage of trust, a craft rooted in compassion, and undermines our commitment to do what’s best for the patient.

GPOs ask manufacturers to pay them pay-to-play fees for product placement in their catalogs.

“I used to travel the country and talk to surgeons about our new stuff,” he told me. “Now I never interact with surgeons.”

“Is the older version ‘clinically acceptable’?” “Clinically acceptable?” I was stumped. Are we shooting for acceptable or excellent?

It’s a simple pay-to-play setup.

Despite multiple lawsuits and several hearings from the Senate Antitrust Subcommittee, little has been done to shine light on GPO practices. The conflicts of interest inherent in the modern GPO business model continue to limit innovation, drive up prices, and cause unacceptable shortages for the most basic drugs and medical supplies.

Today’s wellness movement is a $6 billion industry run amok. More than half of small employers and 85% of large employers offer health and wellness programs, according to a 2017 survey by the Kaiser Family Foundation.1 There’s an army of companies and consultants who can’t wait to get their hands on American workers. Their paydays depend on it. But these so-called experts offer health advice that isn’t always accurate. They’re screening healthy people for diseases they likely don’t have, which often leads to false positives and harmful medical procedures. They’re forcing employees to answer extensive questionnaires that invade their privacy. Does your employer have a right to know how much alcohol you consume, or whether you’re depressed, or if you are thinking about getting pregnant? In many cases, they’re even selling the data they gather.

medical guidelines often stipulate that screening tests should not be done until a certain age. Younger people aren’t at risk for many diseases, so screening can do more harm than good.

screening-industrial complex. Some medical providers see it as a way to bring in business, just like in the D.C. churches.

Wellness companies often make recommendations that go against task force guidelines.

The supposed savings cited by the Safeway CEO was caused by an overhaul of their benefits that passed more of the costs on to employees.

So why do people want to focus on things like lowering central line infections by using the surgery checklist and Safeway model? I think it’s because the real drivers of health care costs are legacy stakeholders, like hospitals, insurance companies, or drug companies, or all the middlemen I’m exposing in this book. There are so many hands taking money out of the system that there’s no silver bullet solution to save money. To lower costs, we must take on the powerful stakeholders. It’s easy to blame bacteria for our health care woes, but infections are not the reason your premiums went up 15% last year.

“The Dubious Empirical and Legal Foundations of Workplace Wellness Programs.”

It’s yet another example of money earmarked for American workers getting diverted into the hands of corporations.

Our medical education system is skewed toward things that don’t matter. It’s focused on rote memorization instead of treating the whole person.

most of our problems in public health are self-inflicted.

How is it that doctors can start off so altruistic and end up so cannibalistic? The answer lies in how we educate and shape young physicians. We credit individuals over teams and promote empire building.

About 10% of what I learned has since been disproved and 80% is as irrelevant to how I practice medicine as the use of Botox on a furry dog.

medical education is controlled by an establishment guard of accrediting boards and institutionalists.

He learned that the way we select and educate physicians is akin to joining a cult. He identified four fundamental traits that get ingrained early: a competitive bias, an autonomy bias, a hierarchy bias, and a noncreativity bias.

What the experts called a “credit default swap” was really borrowed money that bypassed insurance requirements. What experts called a “collateralized debt obligation” was just a group of bad loans. In health care, we do something similar all the time. We need to start fixing health care by switching to a more honest lexicon.

How did medicine transform from a charitable profession to one that has put one in five Americans into collections for medical debt? How did we get to the point where hospitals are scientifically advanced bastions of academic genius, but can’t even tell you what an operation will cost? How did the noble profession of healing allow billing practices to become so predatory that some hospitals sue and garnish the wages of half of the people in the town they serve? How did we get to this point where American businesses have lost their competitiveness overseas because of health care costs? How did we get to a point where Starbucks spends more on health care than coffee beans and General Motors spends more on health care than steel? Or where some types of overtreatment have reached epidemic proportions, and medical error is a leading cause of death in the United States?

Nearly every one of these experts is beholden to one of health care’s big stakeholders and is afraid to speak critically about the entire system.