The Price We Pay

by Marty Makary

  Since my days as a medical student, I’ve seen doctors nudge patients for reasons good and bad. And we doctors are very good at nudging. We know the trigger words that steer patients. Every specialty has its phrases. For obstetricians, it’s saying something like, “It might be safer for the baby.” If an orthopedic surgeon is helping a patient decide between a knee replacement and a nonsurgical option, it’s mentioning the joint is “bone on bone.” The phrase “bone on bone” creates an image of grinding, like fingernails screeching on a chalkboard. Patients beg for it to stop. They choose surgery every time. And if a cardiologist tells a patient he has a “widowmaker” in his heart—an actual medical term used to describe a partially blocked artery—the patient does whatever it takes to address it. No one wants their spouse to become a widow.

  Consider the simple presentation of a patient with early appendicitis. Three trials recently published in top journals show that treating the condition with antibiotics rather than surgery works 75% of the time.5,6,7 And the evidence showed no increased risk of health problems for trying the antibiotic method.8,9,10 More than 300,000 appendectomies are done in the United States each year, each with a hefty price tag. Most of these patients can be treated with antibiotics alone.11 But whether patients choose surgery or a trial of antibiotics depends on how we surgeons present the options.

  I see it in my own specialty of cancer surgery. Some old-school doctors have not learned minimally invasive methods, so they uniformly make large incisions on every patient to access the organs. If a patient asks one of these old-school doctors if an operation can be done with the minimally invasive method, the surgeon could refer the patient to a surgeon who could do it with small incisions. Or the old-school surgeon could drop the trigger phrase “If we use the minimally invasive method, there’s a small chance we may not remove all the cancer.” Guess what? Every patient chooses to be cut wide open.

  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. As Chatrathi discussed this phenomenon, we shared a sad smile. We knew how effective verbal triggers were. All a doctor has to do is suggest that a blockage could be causing the leg pain, and a patient becomes fixated on the idea and agrees to the procedure.

  The recruiting line was simply “Do you have leg pain?” Here’s a better question: Who doesn’t have leg pain? Finding a Medicare patient in America without some leg pain is like finding a penguin in the desert. Leg pain is common in younger people, too. I tried yoga two weeks ago and I’m still limping.

  Once a person admits to even the mildest leg cramp or stiffness or soreness, it triggers a chain of events. The patient might as well be picked up and placed on an assembly line. It starts with the test they did at the church fair—the ankle-brachial index test—to check the patient’s leg circulation. If that warrants further checkup—and that’s often a subjective call—the doctor will say: “Let’s take a look with a handheld ultrasound probe.” What follows is often another test: “Let’s get a better look with a formal Doppler study.” Next, since it looks a bit funny, “Let’s do a diagnostic catheterization.” They inject dye into the patient’s leg vessels and shoot X-rays. “Good news,” the doctor declares. “During the procedure, we found a small blockage that we ballooned open”—or stented, or zapped with a laser. “Come back in a few months for a follow-up to take another look.” By the time they’re done ringing the cash register, Medicare has spent approximately $10,000 per person, a cost that’s passed along to every other American. Private insurance will pay up to triple that amount for the same procedure.

  It may be a scam, but it’s perfectly legal. The doctor carefully documents that the patient has a diagnosis of “claudication” to ensure that everything will be covered by insurance. Claudication is a rare type of debilitating leg pain that is subjective and nearly impossible to disprove. And even though doctors know that less than 5% of patients with this rare diagnosis benefit from surgery, inserting that single word once in a patient’s chart guarantees the doctor will be paid in full and fend off any lawsuits. The crafty documentation sidesteps the national guidelines. In addition, the American College of Preventive Medicine has taken a stand against the screenings, warning that the false positives lead to unnecessary downstream tests, procedures, and psychological distress.12

  As I spoke to Chatrathi, my mind was reeling. I had to pause to absorb what I was hearing: unsuspecting citizens were being systematically targeted for factory-style procedures. Their mistake? Wanting to take care of their health.

  Telling the truth can get doctors in trouble with their peers. I wanted Dr. Chatrathi to feel free to speak honestly, so I offered to keep his name out of this book. He would have none of it.

  “I don’t want anonymity,” he said. “That’s the problem. We have all been silent about all the waste in medicine, even as everyday people pay higher and higher health care costs. Use my name. I’m aware of the consequence to my practice. But it’s time we as doctors stand up to say what is right and wrong.”

  Digging Deeper

  After several conversations with Chatrathi, I decided to bring up the issue with my Johns Hopkins research team. At our next meeting, I explained to them what I had learned. My team of ten sat there listening in shock. Our group studies health care costs, so this story struck a chord. Their outrage was palpable. It was especially strong among the millennials, who I find have a low tolerance for injustice.

  Dr. Caitlin Hicks, our surgery department’s newest hire, took a special interest. She’s a rock star. After graduating from Harvard and the Cleveland Clinic, Hicks trained for 6 years at Johns Hopkins to become a vascular surgeon. Everyone in our department had been impressed by her technical genius and research productivity, and I was lucky to have her on my study team. As I explained what I’d seen “in the field,” Caitlin listened and maintained her composure, but I could tell she was seething. She had heard of doctors making a ton of money by stretching the indications so they could balloon and stent leg vessels. Eventually she spoke up, proposing we conduct a national study to see how prevalent the practice had become. She had written a hundred scientific articles as a medical student and trainee. Having Caitlin on the case was a huge asset.

  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 We generated a county-by-county U.S. map showing where the procedure rate was highest. What we saw was infuriating. We were looking at a map of predatory screenings for unnecessary surgery. At our research meetings in my office, Caitlin and others on the team would present the findings in a scientific tone but get choked up when they considered what was happening to vulnerable Medicare patients. I admired their passion.

  I decided to visit more church fairs, and I found that the D.C. city government promotes the events. It seems like every week in the summer months, a local church offered community screening for leg circulation—and not just for leg circulation. My team found a host of other unwarranted health screenings, such as checking the carotid arteries in the neck and doing EKGs on people without heart symptoms.

  One of the offending surgery centers had four full-time marketing employees. They recruited patients using the same tactic I’d witnessed at the church outreach event—by inviting people to see if they have poor blood flow in their legs. It’s a scheme they undertake in churches, supermarkets, referring physician offices, and community health fairs. Some community residents receive spam mailings encouraging them to come in for screening.

  One of the young members of our research team, Will Bruhn, insisted on joining me on my next ch
urch fair visit. One bright Saturday morning, we walked into a church plastered with signs advertising the free health fair. After signing in, we entered the fellowship hall, where table after table offered information about prenatal care, exercise programs, and a host of other topics. Then, over in the corner, we spotted him. A doctor sat in a chair with a Doppler ultrasound probe in his hand. He squeezed a generous dollop of lubricant onto the thigh of the woman sitting beside him, then ran the probe up and down her leg. When she got up, he handed her his card and the next person in line took a seat. It was like watching a round of speed dating.

  Will and I got in line. We wanted to hear what the doctor was telling people. While waiting, we were presented with marketing materials. The images in the brochures showed a blockage in a leg artery and illustrated how a balloon or stent could open it up. When our turn came, the doctor refrained from doing an ultrasound, but he explained that he was helping people with varicose veins and checking for blockages in the leg arteries. Varicose veins are typically a cosmetic problem. But the pamphlets and posters at the church fair made them sound life-threatening.

  For months, Caitlin, Will, and I continued to visit church health fairs, regrouping between visits with the whole team to study the magnitude of the problem and the broader cost implications. Will and I took photographs, conducted interviews, and documented the profit-driven screening. The research team produced figures, tables, and maps that described the predatory nature of the procedures. With every new piece of data, we got a clearer vision of the big picture—and it was distressing. With every trip to a church health fair, we were saddened to see happy, grateful people, mostly African Americans, being fleeced by white physicians and their staff. What we personally observed was consistent with what Caitlin’s maps had indicated.

  I wanted to see what the pastors thought about this. Did they know that the procedures being recommended at their church fairs were probably unnecessary? I returned to the first church where I had attended a fair, and the pastor graciously welcomed me into his cluttered office. He took a minute to introduce me to his wife, who helped run the church school and worked in an office a few feet from his.

  We sat down and I explained to him what my team had witnessed locally and studied nationally. He was flabbergasted. “We don’t know the medical science,” he said. “We just wanted to serve our community and invite people into our church. Some churches do food giveaways. We always wanted to do more.”

  It’s an admirable goal. It can be hard to get access to good care in low-income neighborhoods. A few times during the conversation, the pastor referred to the health fair as health “care.” He talked about how people need health care and he wanted to help provide it. But after our conversation he said he felt used by the doctors he had been letting into his building. After that meeting, the pastor banned the vascular screening group from coming back to his church’s health fairs.

  Will Bruhn would go on to write studies on the harms and costs of overscreening, and Caitlin led a national effort to address predatory screening for peripheral vascular disease. We didn’t want to wait a year for the medical journals to review and publish our findings. So we summarized the problem in a letter to Society of Vascular Surgery, urging them to take action, and met with the leaders of Medicare to show them what we found in their data. Caitlin’s standing in the field of vascular surgery enabled her to raise awareness and propose a project to address the physicians who seemed to be performing the most unnecessary procedures.15 Ultimately, the experiences we gained helped us shape a national project that I’ll explore further later in the book, called Improving Wisely, a multistakeholder collaborative aimed at addressing the issue of appropriateness in medicine.

  I reached out to more pastors in minority communities around the country and again took to the road to learn more. After attending a conference in Duck, North Carolina, where I spoke about the overscreenings targeting black churches, a hospital board member in the audience walked up and thanked me. His name was Bishop Kim Brown, pastor of Mt. Lebanon Baptist Church, a large, predominantly African American church serving the northern North Carolina and southern Virginia area. I shared more of my team’s research findings with him. He was upset but not surprised, responding “This makes sense. Doctor groups and wellness companies are always calling us trying to get in our churches.”

  I assumed Bishop Brown was talking about church health fairs, but what he said next really shocked me. “Sometimes they want to come do health fairs, but sometimes they want to come in on Sunday after the service and set up a screening area,” he said. 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.

  I explained to him that some of these tests were unwarranted and done to create downstream business. Bishop Brown thanked me. “We are just trying to take care of our people,” Bishop Brown told me. “Unless someone with expertise is honest with me, I don’t know what to believe.”

  Getting Proximate

  The business of medicine operates in even more disturbing ways. My next series of trips would teach me how the modern-day business model has even ventured into price gouging and predatory billing. Collectively, the two root issues driving health care’s cost crisis—the appropriateness of care and pricing failures—would become increasingly vivid. In total, the many examples of clinical and administrative waste I witnessed violated everything my father, a cancer specialist, had taught me about being a good doctor. Yet every time I was tempted toward cynicism, I encountered people fighting back, innovators and visionaries who are disrupting health care to address these underlying problems and lower your health care costs. This book is my way of sharing their stories with you. By being proximate to the problem, they are charting a way forward.

  After I left my meeting with the D.C. pastor, I drove home. Again, I passed the U.S. Capitol building. Though it was getting dark, I could still make out the flags around the Washington Monument flapping in the cool evening wind. At that moment Congress was meeting in a special session to talk about health care funding. As I passed the U.S. House of Representatives, I wondered if they had the slightest idea of what was truly crippling health care. The politicians debated how to fund health care, but what we really need to talk about is how to fix health care. While they made grand speeches and exchanged rhetorical fire on the issue of funding, the business of medicine was humming just down the street, in the churches of our nation’s capital.

  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.

  CHAPTER 2

  Welcome to the Game

  My listening tour began locally with Henri, a master’s degree student at George Washington University. Everything had gone well at the university’s Parents’ Weekend until Henri’s dad, Adam, started getting chest pains while out for dinner. Adam was from France, so falling ill on the other side of the ocean created a crisis. Unfamiliar with the U.S. health care system, the famille was about to get an education.

  Henri and his dad went to the closest emergency department, where the doctors discovered Adam had suffered a minor heart attack. The doctors stabilized him with medication and he spent a night in the facility. The next morning the doctors recommended a heart bypass operation—electively, that is, sometime in the coming weeks. Before Adam got discharged, a hospital representative came to his bedside to talk finances. He explained that the operation would cost $150,000.

  Henri and his parents had no way to know whether this was a fair price. They called a family friend who put them in touch with a good heart surgeon in France. Over the phone, the French surgeon explained that the quality of the operation would be the same in France as it would be in the United States. The family timidly asked how much the operation would cost in France. “About 15,000 U.S. dollars,” said the French surgeon.


  Soon after, the local hospital representative who provided the $150,000 quote visited Henri’s dad again to ask about their plans.

  “Quite honestly, we are thinking of having the surgery in France for $15,000,” Adam said.

  Without hesitation, the hospital representative dropped the price to $50,000.

  Alarmed at the sudden discount, Adam politely declined the offer and booked his flight to France. But as he walked out of the facility, the hospital representative approached him in the hallway one last time. Desperate to close the deal, the hospital official made a final offer: “Okay, we’ll do it for $25,000.”

  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.

  Adam had the surgery in France for $15,000 with a good outcome. “We loved our American doctors,” Henri told me over a drink. “It was the business of medicine that turned us off.”

  The way the hospital haggled with Henri’s family reminded me of Egypt’s famous Khan el-Khalili bazaar, the largest open-air market in the world. The bazaar makes the floor of the Chicago Board of Trade look like a Presbyterian prayer group. It’s a bustling shopping center for Egyptian locals and a tourist trap extraordinaire for any foreigner, especially if you wear a fanny pack. The millions of items of merchandise are sold without a price tag. Instead, the prices are set by how much merchants think they can get someone to pay.

  The Arabic merchants are so good they have a global reputation for their sales tactics. They track your eyes to see what you look at twice and what makes you smile. If you ask the price of an alabaster replica of one of the famed Egyptian pyramids, they tell you it’s $100. It may be worth $1. Some tourists fall into the trap and fork over the full price. Others nervously ask for a small discount and then pat themselves on the back for paying $90. The real wheeler-dealer shoppers counteroffer even lower and negotiate the price down to $50. They walk away bragging about their great deal. But it’s the merchant who invariably wins. That’s the markup and discount game.