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

by Marty Makary

The doctors replied that, on average, they believe 21% of everything done in medicine is unnecessary.4 Breaking it down further, the doctors in that survey estimated that 22% of prescription medications, 25% of medical tests, and 11% of procedures are unnecessary. Literally billions of dollars are spent on care we don’t need. Public

Patients make decisions based on how we present options to them. We just give them a nudge.

Our team eventually identified about 1,100 U.S. churches, synagogues, and mosques that served as vascular screening centers13—despite a scientific consensus that people should not be screened this way for this disease. Caitlin also worked on a national study of Medicare patients that revealed it was mostly minorities or people in low-income areas getting these procedures, even after accounting for contributing factors such as smoking or disease complexity.14

The range of prices was astounding, from $44,000 to $448,000. Did they use gold-plated surgical instruments? No. Was the center that charged ten times more the one with the best outcomes? Nope. Heart surgery outcomes are publicly available. The research showed no correlation between surgery price and quality.

Hospital officials confessed that they inflate bills more and more each year to generate more revenue since their insurance companies pay only part of the sticker prices. Insurers confessed they demand bigger and bigger discounts in their contracts with hospitals in order to keep up. Both acknowledged that they pass on higher hospital bills to the public in the form of higher insurance premiums.

“Insurers fight for a bigger discount every time they renew a contract with a hospital. Then hospitals go around and inflate their prices. It’s a game.” He seemed disgusted by the markup-discount games everyone in health care has come to accept as standard operating procedure.

Our next stop was the local Amtrak train station where we learned that some trains are half-full of Amish people taking the six-day ride to Mexico for medical care. Mexican hospitals even advertise in the Amtrak magazine. It’s incredible how far people will go for honest medical pricing.

I asked my research team to study the few medical groups in the country that have gone from the old way of doing business—giving patients sticker shock after their surgery—to doing business with full price transparency. Our study was led by Dr. Ambar Mehta, an inquisitive Hopkins medical student who is now a surgical resident at Columbia University Medical Center in New York City. His findings were dramatic. Centers that initiated full price transparency saw a 50% increase in patient volume, a 30% increase in revenue, and an increase in patient satisfaction.17 People are sick and tired of the game.

Dr. Dinner’s “complication rates” were probably superb. As we surgeons know, if you are operating on healthy people who don’t need surgery, your complication rate will be close to zero.

The idea is ludicrous. Where I’ve challenged academic elites is that the randomized controlled trial design of research was developed to test medications compared to a placebo. Thankfully, others have spoken up as well. An entire issue of the journal Social Science and Medicine was recently devoted to it, with many articles pointing to the shortcomings of randomized trials.1 Here’s one way to think of it: randomized controlled trials are not the way one should evaluate whether a parachute is effective in saving the lives of skydivers.

The liberal use of “no evidence to support” has conditioned us to distrust anything not supported by trial. I’ve taught my students and residents to do better, replacing the sloppy phrase “There is no evidence” with either “It is unknown because it has not been adequately studied” or “It has been studied adequately and has not been shown to be effective.”

Best practices in the specialty have matured. The vast majority of these hernias close on their own as the child grows. It’s recommended that surgeons wait until a kid turns six or seven. On top of that, new research has found that general anesthesia in young kids can be associated with learning disabilities. Bottom line: there are only rare cases when a surgeon needs to close an umbilical type hernia in a child under age four. (Inguinal hernias are a different matter.)

That night, I learned things they don’t teach in health policy textbooks or graduate schools. I learned, in vivid detail, exactly how insurance brokers get kickbacks for selling health insurance and pharmacy benefit manager plans to employers, just as Contorno had explained to me. I realized that brokers are often the shepherds leading the sheep. They can convince an employer to buy an overpriced plan or a great value plan. They can convince an employer to switch insurance carriers, stick with their current carrier, go to the mat for a better price, or bypass health insurance and simply self-insure. Brokers have a lot of power. Employers grow to trust them. But what employers don’t know is how insurance companies use cash to control the brokers. At the Orlando conference, I heard story after story of companies calling brokers to dangle a big bonus in front of them if they kept an employer on the hook. I

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.

As a gastrointestinal surgeon and advocate for healthful foods, I’m well aware how this low-fat teaching is based on the medical establishment’s embarrassing, outdated theory that saturated fat causes heart disease. A landmark 2016 article in the Journal of the American Medical Association found that the true science was actually being suppressed by the food industry.4

Highly respected medical experts like my former Johns Hopkins colleague Dr. Peter Attia are now correcting the medical establishment’s sloppy teachings. He and many other lipidologists know that the low-fat bandwagon has damaged public health. It was driven by an unscientific agenda advanced by the American Heart Association and the food industry, which sponsored the misleading food pyramid. These establishment forces spent decades promoting addictive, high-carbohydrate processed foods because the low-fat foods they endorsed require more carbohydrates to retain flavor. That 40-year trend perfectly parallels our obesity epidemic.

Despite science showing that natural fats pose no increased risk of heart disease and that excess sugar is the real dietary threat to health, my hospital still hands every patient a pamphlet recommending the “low-fat diet” when they’re discharged from the cardiac surgery unit, just as we have been doing for nearly a half century. But nowhere is that now debunked low-fat recommendation propagated as much as in wellness programs.

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.

Workplace wellness advocates hailed the support provided by the Affordable Care Act as a public health victory. Soon there were promises of lower rates of chronic disease and lower health care costs. Wellness companies began to pop up all over. Wellness programs began to require people to answer extensive questionnaires that delved into their privacy. Wellness programs provide only a modest profit, so companies began to sell their employees’ collected personal health data to third parties. That was a good business model. On the open market, health data is coveted. Where is the science to show that the enormous societal investment in wellness programs makes people healthier? It’s nowhere to be found. The evidence we do have does not show that these programs are effective.

In 2017, four members of the team behind the Incidental Economist blog published an extensive assessment of wellness programs and the evidence of their effectiveness. The title of the paper speaks for itself: “The Dubious Empirical and Legal Foundations of Workplace Wellness Programs.”13 They declared that most studies on the efficacy of the programs suffered “serious methodological shortcomings. Some are little more than thinly veiled promotional materials pulled together at the wellness industry’s behest.”

In 2018, researchers from the Illinois Workplace Wellness Study published a large randomized controlled trial of a wellness program conducted at the University of Illinois at Urbana-Champaign. The study included nearly 5,000 employees who agreed to participate; some employees were invited to receive a biometric health screening and an online health risk assessment and offered a number of wellness activities. Employees were paid for completing screenings and participating in activities. The researchers followed the employees to see how the program affected their activities, their health, their productivity, and their medical spending. In the final analysis, there was no difference between those who did the wellness program and those who didn’t. In the words of the New York Times, “The results were disappointing. There seemed to be no causal effects.”14 Most recently a JAMA study of 32,974 employees randomized to participate in a wellness program found “no significant differences in clinical markers of health; health care utilization, absenteeism, or job performance.”