The Price We Pay

by Marty Makary

  Dedicated to my father, whose compassion in caring for cancer patients has taught me that part of being a doctor is the responsibility to advocate for those who are most vulnerable

  BY THE SAME AUTHOR

  Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care

  Mama Maggie: The Untold Story of One Woman’s Mission to Love the Forgotten Children of Egypt’s Garbage Slums

  Contents

  Preface

  Part I: Gold Rush

    1.  Health Fair

    2.  Welcome to the Game

    3.  Carlsbad

    4.  Two Americas

    5.  The Ride

  Part II: Improving Wisely

    6.  Woman in Labor

    7.  Dear Doctor

    8.  Scaling Improvement

    9.  Opioids like Candy

  10.  Overtreated Patients like Me

  Part III: Redesigning Health Care

  11.  Starting from Scratch

  12.  Disruption

  13.  Buying Health Insurance

  14.  Pharmacy Hieroglyphics

  15.  4K Screens

  16.  Diagnosis: Overwellnessed

  17.  The Words We Use

  18.  What We Can Do

  Acknowledgments

  Notes

  Index

  A Note on the Author

  Preface

  Sometimes when I sit down to write, I find myself staring at a blank screen. Before I know it, I’m buying toothpaste online. Writing this book was entirely different. As I traveled to see what American medicine looks like on the ground, I would rush back to my computer to write.

  Over the past two years I visited 22 cities across America, listening to each of health care’s stakeholders: hospital and insurance company leaders, policy makers, doctors and nurses and others. I’ve also sat with scores of patients—in living rooms, over dinner, at work—and they’ve shared with me, sometimes through tears, how the business of medicine ruined their lives. I spoke with numerous insiders who went into health care for noble reasons but found themselves caught up in a system they despise. I was also inspired by innovators who refused to accept the status quo, redesigning medical care and launching businesses aimed at disrupting health care by cutting through all its shenanigans.

  My goal has been to understand the business of medicine and to examine it through the lens of its clinical mission of serving patients. Surprisingly, this exhilarating trip was not entirely different from my work as a surgeon. I’ve been “making rounds” on patients, but this time it was to see their wounds from the health care system rather than from surgery. Along the way, I learned what no health care textbook or classroom could have taught. I learned the money games of medicine.

  As I cared for patients back home, between my travels researching this book, I was often reminded of the deep trust people have in their doctor. Patients are willing to let me put a knife to their skin within minutes of meeting me, or to divulge secrets they’ve kept for a lifetime—just because I’m a doctor. In exchange for this trust, doctors like me promise to do our best to help, a contract articulated in the Hippocratic Oath. Similarly, most American hospitals were founded with a charter dedicating them to care for the sick and injured regardless of one’s race, creed, or ability to pay. But tragically, that heritage of public trust is threatened today by a business model of price gouging and inappropriate care. However, a groundswell of doctors are saying, “No more.” We must restore medicine to its noble mission.

  For centuries, medicine was based on an intimate relationship between doctors and patients. But behind the scenes, a gigantic industry emerged: buying, selling, and trading our medical services. Health care industry stakeholders are playing a game, marking up the price of medical care, then secretly discounting it, depending on who’s paying.

  When a $69,000 bill hit one New York woman for a simple two-hour ER visit, she turned to my friend for help. She had only needed an IV and some basic tests, so she couldn’t believe the price. My friend, a health care consultant, had a good relationship with the hospital’s CEO so he met with him and told him about the two-hour visit in detail. “Guess how much your hospital charged?” my friend asked the CEO.

  Cringing, the hospital CEO guessed $5,000, thinking he was guessing high. Then my friend showed him the itemized bill totaling $69,000. Embarrassed at how disconnected he was from his own hospital’s billing practices, the CEO offered to forgive the bill.

  This story reminded me that we don’t have malicious leaders in health care; we have good people working in a fragmented system. The operations I do today use the same equipment, anesthetics, sutures, and paid staff that I used ten years ago. So how is it that health insurance costs have been skyrocketing? It’s explained by the money games of medicine, loaded with middlemen, kickbacks, and hidden costs.

  The profits are big but the casualties are great. Overtesting, overdiagnosing, and overtreatment are now commonplace in some areas of medicine.1,2,3 And the prices are so high that patients can’t pay the bills. About one in five Americans currently has medical debt in collections and half of patients with certain medical conditions, such as women with stage 4 breast cancer, now report being harassed by a collection agency for their medical bills.4

  While patients are getting shaken down for inflated bills, the health care establishment conducts high-level panel discussions in gilded conference rooms discussing the issues in theoretical terms. I’ve been there. I sit on those panels too. But to understand what was really happening in health care, I shed my white coat and embarked on listening rounds across the country.

  While these travels gave me the education of a lifetime, they also gave me new hope. I visited hospitals and start-ups charting new courses with fresh ideas. I met doctors, business leaders, insurance innovators, state legislators, millennials, and others fed up with the medical establishment and challenging it. This social movement has no formal name or membership, but is made up of people determined to put patients back at the center of medicine. They are working to make how you pay for medical care rational and fair instead of secretive and predatory. Using the simple principles of transparency and competition, they are showing us the way out of this mess. This book shines a light on many insider games of health care, but it will also introduce you to the innovators and disrupters working to save you money.

  My favorite movie is The Big Short, a film about the financial crisis of 2007. Part of the reason I admire that movie is because it took an incredibly complicated problem and made it understandable by using stories and relatable examples. In this book, I want to do the same for American health care.

  Before the Great Recession of 2007, Americans were being led to buy mortgages they didn’t understand and could not afford. As I talked to families and business owners who purchased health care they didn’t understand and couldn’t afford, I began seeing ominous signs that health care has become another economic bubble.

  A woman in California helped me appreciate the burden that our rising health care costs place on small businesses. To start her dry cleaning business, Jennifer had to pay $100,000 a year to get health insurance for herself and three employees.5 Right off the bat, her small business was six figures in the hole. How many more garments does she now need to clean in order to be profitable? Jennifer’s story illustrates one of the greatest risks to our economy: health care costs are increasingly suffocating business in America.6

  The 2007 banking crisis resulted from complexity that kept onlookers confused. When people questioned banks being overleveraged and selling mortgages to people who couldn’t afford them, financial
experts responded by saying, “It’s extremely complicated. Leave it to us.” But the problem was simple: Banks were spending money on toxic assets with money they didn’t have. Bad mortgages were bundled and sold on the market for more than they were worth. Credit ratings agencies, supposedly independent, received payments to prop up this house of cards. The result was a huge economic disaster.

  Today, entrenched stakeholders in medicine fend off criticism by claiming these highly complex systems should be left to the experts. “You wouldn’t understand … leave it to us.”

  But we do understand, and it’s time to change the business of medicine. This book is my attempt to push back. We currently spend enough money to provide excellent health care to every American. It’s time to cut the waste.

  PART I

  Gold Rush

  CHAPTER 1

  Health Fair

  The Washington Monument, encircled by American flags, loomed tall and proud that sunny morning as I made the 20-minute drive through D.C. from my home in Virginia. I arrived at the office of Dr. Sridhar Chatrathi. He worked in Prince George’s County, a predominantly African American suburb of Washington, D.C. I learn a lot from talking to community doctors like Chatrathi. In the lobby of his cardiology clinic, he welcomed me with a cheerful smile before ushering me into his office. Skipping the pleasantries, he got straight to the point. A fast-growing trend he was witnessing weighed on his conscience: doctors doing unnecessary vascular procedures.

  “It’s the Wild West,” said Chatrathi. “Ballooning, stenting, and even lasering harmless plaques in leg arteries has spun completely out of control. It’s a cash cow.” He explained that within two miles of his office, there were four surgery centers doing these procedures all day long, every day.

  “Ballooning” and “stenting” refer to the way doctors insert tiny inflatable devices or wire cages into arteries to spread open blockages that restrict blood flow. It’s been going on for decades, but primarily in heart vessels. Such procedures can be lifesaving for someone experiencing a heart attack, but for most other patients, studies show stents provide no survival benefit. Because of that, heart stenting is in decline, replaced by better medications. In recent years there’s also been a lot of public scrutiny of the practice. A Baltimore cardiologist, Dr. Mark Midei, received a great deal of negative media attention for allegedly placing unnecessary heart stents in hundreds of patients.1

  “The Midei headlines had a big impact on the field and sent a strong message to cardiologists,” Chatrathi told me. “It helped clean up the practice of overstenting heart vessels.”

  Nonetheless, Chatrathi said, his peers—kings of a past era of stenting heart vessels—have found a new way to use their skills. Or perhaps I should say a new place: the legs. Ignoring guidelines of the U.S. Preventive Services Task Force that clearly state that there is no evidence to support screening for peripheral artery disease,2,3 many of them do a test to see if there are any blockages in the leg arteries, and then follow up with a procedure to improve circulation. Heart stenting nationwide was on the decline. But leg is the new heart.

  One thing puzzled me, though. It’s not as if patients just book appointments to have cardiologists check out their leg circulation.

  “Where are they finding all these patients?” I asked Chatrathi.

  “In churches,” he replied.

  What!? I was confused. I’m a churchgoer, and I couldn’t imagine doctors looking for customers in the pews. It’s not as though doctors can just show up for worship services and offer the congregation surgery in the lobby afterward.

  Chatrathi explained that churches hold community health fairs at which doctors show up and perform predatory screenings. I had to see this for myself. I tracked down an upcoming health fair at one of the churches in his area and a few weeks later went on another research field trip.

  Once again, I let myself take in the scenery that morning as I cruised through our nation’s capital. Though I’d been through D.C. countless times, I drove slowly, soaking in the stately surroundings. The Capitol dome stood graceful and white. I arrived at a church building where an African American congregation meets, minutes from the U.S. Capitol building. I walked inside and found a gathering of life and smiles.

  A woman from a local cardiology group ripped a Velcro blood pressure cuff off an older woman’s arm. “Let me do that again,” she said warmly.

  The congregants had turned into patients. It might seem like a selfless act of community service. After all, here were medical providers examining patients in a church filled with underserved minorities. But after talking to Dr. Chatrathi, I saw this scene in a different light. These medical providers weren’t serving; they were prospecting.

  The person from the cardiology group was conducting a test that measures how the blood flow in the legs compares to the blood flow in the arms. The rationale: Something might be wrong if the blood pressure is lower in the legs. It could be caused by a narrowing of the arteries, a plaque that slows blood flow. It might warrant further investigation.

  There’s just one problem with that notion: This test should not be performed unless a patient has serious symptoms, like crippling leg pain. For anyone else, it’s likely to lead to medical care they don’t need, which can be expensive and dangerous. That’s exactly why independent medical experts do not recommend the type of peripheral vascular screening I witnessed that day at the church.

  The dutiful patient being examined didn’t seem to have any severe pain in her legs. In fact, the team seemed to be testing as many people as they could. The woman from the cardiology practice told the patient her reading was “borderline.” She gave her instructions to follow up for ultrasound testing at the cardiology group’s vascular center.

  The medical provider convinced her that she cared only about her well-being, not telling her the other side of the story. The young woman administering the screening may have been unaware of national guidelines about this type of testing and, with good intentions, convinced herself that plaques are evil. And the woman being tested probably thought testing was good for her health. She would be responsible for a small portion of the cost, but all of us would pay for the rest of her bill through the Medicare program. The doctors stood to make a lot of money for each follow-up test that resulted from the church fair. Rather than showing up to help patients, this practice was panning for gold.

  Attending the church outreach event that day offered me a fresh reminder that health screening can be a double-edged sword. It can be a powerful tool to detect disease and prevent tragedy. But it can also be a business model to recruit patients for treatments they don’t need. In an instant, overscreening converts a community of average residents into a pool of patients. It’s just one costly example of the medicalization of ordinary life.

  Do You Have Leg Pain?

  Doing leg procedures for people that don’t need them is one form of unnecessary treatment. But the problem is even bigger. I worked with my Johns Hopkins colleagues to estimate the percentage of medical care that is unnecessary by sending an anonymous survey to a sample of 3,000 doctors across America and had 2,100 respond. 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 health crises can be divided into two types: naturally occurring and man-made. Many of the crises we face in medicine today are not naturally occurring viruses or other hazards from nature. They are manufactured, like the crisis of smoking, or opioid addiction, or antibiotic resistance. Similarly, too much medical care is a public health crisis that harms patients and wastes our health care dollars.

  Even before meeting Dr. Chatrathi and attending the church health fair, I had become aware of unnecessary procedures on leg vessels from conversations I’d had with my friend Jim Black, chief
of vascular surgery at Hopkins. When we were in the operating room together, he discussed the outlandish things some other doctors in the community had told his patients. Jim said some doctors justified these unnecessary procedures by telling patients it would improve their circulation. One doctor, he said, routinely told patients that the procedure would prevent an amputation in the future.

  It’s common for older patients to have some narrowing of leg arteries. The femoral leg artery is long, and some narrowing is normal. It’s called peripheral artery disease. But the body usually adapts. If surgeons operated on every artery narrowing, we’d be operating multiple times on nearly everyone over 70 years old. But intervening with endovascular procedures is so easy and lucrative that cardiologists are not the only doctors to get into this unregulated area. Radiologists and vascular surgeons are also doing the procedures. Leg artery procedures can generate $100,000 in one day when a doctor owns the facility. By comparison, I earn about $2,000 per day doing cancer surgery. Doing a procedure pays well, but taking time to explain the importance of exercise, which increases leg circulation, pays poorly. I already knew our medical system gives incentives for us to perform procedures, whether patients need them or not. But the church health fair had vividly shown me just how prevalent unnecessary medical care had become.

  Over the course of several conversations I had with Dr. Chatrathi, he explained the mammoth scale of the deceptive practice. Many private vascular centers in Washington, D.C., he said, are lining up a dozen or more patients per day.

  “For the vast majority of cases they are doing, there is no evidence to support the procedure,” Chatrathi said.

  I asked Chatrathi how the doctors convince patients to undergo the procedures.

  “They ask people, ‘Do you have leg pain?’ ” he replied with a smirk.

  I smirked too, knowing what all doctors know: Patients make decisions based on how we present options to them. We just give them a nudge.