by Marty Makary
“Wait, wait, hold on,” I interrupted. “You had the balloon sinuplasty procedure? Tell me about that.”
While working on the Improving Wisely project, our research group and Ear, Nose, and Throat (ENT) specialists criticized the balloon procedure. The widespread use of the procedure evoked negative reactions from the experts.
Based on these reactions, I decided to study the issue further. I led a focus group with ENTs and asked how a balloon sinuplasty works. An expert showed how a balloon at the end of a small tube is inserted into the patient’s sinus and inflated to open the sinus opening. It rarely works, said the ENT doctor, and is widely overused. The other ENTs in attendance had smiled at the obvious reason everyone does them: they pay well. Intense frustration with doctors who balloon nearly every patient was palpable.
I asked if there was a group of patients the procedure did help. They shook their heads. Not really. “It’s necessary for less than 5% of patients who are getting the balloon done,” said one doctor. After the meeting, one of the Hopkins ENTs pulled me aside. “Doctors are taking patients for a ride,” he said.
Given the widespread abuse of this procedure, you can see why Karen had my attention. Now I leaned toward her, and my voice dropped an octave as I asked her to share all the details. “Please, tell me everything.”
She explained how the doctor placed a small tube in her nose and then inflated a balloon to open up her sinuses. She made a point of mentioning that the doctor is a very good, highly recommended doctor with gorgeous offices. The clinic even had palm trees in the lobby, she said.
“Did the balloon help with your sinus problem?”
“Umm, not really,” she confessed. That’s what the experts would have predicted.
“How long did the whole procedure take?”
“About 45 minutes.”
“Was it done in an operating room or in the doctor’s office?”
“The office.”
“How much did it cost?” I asked
“Oh, my, the bill was $21,000,” she said. “Thank God I only had to pay $2,500, and my insurance covered the remaining $18,500.”
A $21,000 bill for a procedure taking less than an hour with no operating room costs? And it didn’t even work. I was shocked.
Karen seemed content that the bill was resolved and her portion was only a fraction of the total cost.
“Do you know what an open heart surgery costs at Johns Hopkins?” I asked. She didn’t. I told her it was about the same cost.
Whether the balloon procedure was indicated for in Karen’s chronic sinusitis, I can’t say for sure. But a few things were clear. One, my Hopkins colleagues believe the procedure is vastly overused. Two, Karen reported no benefit. And three, Karen and her insurance company were victims of price gouging.
Many people assume that insurance companies have safeguards against price gouging, but not so in Karen’s case. The same is true for millions of cases like hers where the medical billing is too complicated and unclear to figure out. Insurance companies pass on the expense to everyone in the form of next year’s premiums.
Karen’s story captured everything wrong with health care today—and many of the things I’ve detailed in this book. She was price-gouged for a procedure she didn’t need after taking medications that were marked up by her pharmacy benefits manager (PBM). All the while, she was oblivious to the many ways she’d been taken advantage of.
Karen’s experience reminded me of a woman named Rhonda who brought her son to their doctor for a sports injury. The doctor ordered an MRI of the kid’s brain, even though there was no head injury and no loss of consciousness. Following the doctor’s orders, her son had the MRI, and she was charged 12 times more than she would have been at the other MRI center about a mile down the street. A single working mom with a $9,000 insurance deductible, she paid the uber-inflated MRI bill using the money she had saved up for her son to go to community college. For the first several months after she got the bill, she, like many Americans, did not have the cash on hand to pay it, and the bill was sent to collections before ultimately she paid it in full. Her FICA score was hit and, buying a small home around that time, she ended up having to pay more for her mortgage.
Physicians and hospital leaders who had no knowledge of how ugly their billing procedures had become are now becoming aware and are doing something about it. Some are talking to their hospital executives and board members to take a pledge to never sue low-income patients and to bill fairly. My team, in partnership with BrokenHealthcare.org, continues to travel to U.S. hospitals, politely asking them to make their billing procedures consistent with their hospital’s charter and mission statement. The grassroots movement has also spread on a local level, to students, medical professionals, and concerned citizens who are demanding that hospitals examine their fairness in billing and do more to restore the public trust.
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?
How did we arrive at this moment where pharmacists are contractually forbidden to tell a patient what’s in their best interest, and middlemen work in a fog of transactions so opaque that a special law was passed to grant them exemption from antikickback laws? These money games become so accepted that ordinary people like Karen are getting charged $21,000 for an ineffective minor procedure, and meanwhile, she has no idea that she’s a victim of the game.
Historically, hospitals were founded on an altruistic mission to serve their communities. They were sustained by charity and committed to great values of equality. My hospital was founded by Mr. Johns Hopkins. He described his mission in a March 10, 1873, letter, saying he would care for “the indigent sick of this city and its environs, without regard to sex, age or color, who may require surgical or medical treatment, and who can be received into the Hospital … The poor of this city and State of all races, who are stricken down by any casualty, shall be received into the Hospital without charge.”1 Like most hospitals in America, Johns Hopkins was founded on and dedicated to the principles of compassion and mercy.
The Johns Hopkins Hospital operated in the red for its first eight decades. The annual deficits were covered by gifts from trustees and by dipping into the endowment. Their commitment to serve the community was unwavering. Many landmark cases at Hopkins were performed at no cost. The pioneering craniofacial operations and the separation of conjoined twins connected at the head were done gratis. For free.
I’m inspired by the individual health care professionals who have sacrificed so much to improve the lives of patients. I think of Dr. Walter Dandy, a pioneer in neurosurgery who lived in the early 1900s. He developed the first ICU and performed the first vascular clipping of a cerebral aneurysm. Though considered a strict, firm-tempered man, he was also extremely generous.2 He often paid the hospital expenses of indigent patients. On one occasion, when he learned that the mother of a patient could not afford the train fare to bring her child to Baltimore, he not only paid her way but refused to take any compensation. Dr. Dandy, known as the father of cerebrovascular neurosurgery, routinely declined to accept payment from teachers, police officers, or firemen. He was a dedicated and busy surgeon. He even wrote a letter to Dr. Harvey Cushing on June 30, 1921, about the medical establishment of his day, saying that he was “very
averse to joining societies of all kinds because I feel they are more social than beneficial and I cannot spare the time for them.”
The day the polio vaccine was announced as safe and 90% effective, Jonas Salk refused to commercialize it or obtain a patent. He and polio vaccine developer Albert Bruce Sabin, a physician at Johns Hopkins, refused to make money from their discovery. Salk and Sabin had seen firsthand how polio paralyzed as many as 20,000 children each year, sentencing some to life in an iron lung machine. Our hospital had wards of them. But Salk and Sabin believed that the polio vaccine was the property of humanity. Because of their compassion, most of the world’s children quickly had access to the medical breakthrough. Forbes estimates that Salk alone would have been richer by $7 billion if his vaccine had been patented. Salk and Sabin stayed true to their medical calling to help people and considered their vaccines to be donated for the benefit of mankind.
Dr. Benjamin Rush, son of a blacksmith, remembered his Philadelphia roots growing up in a family without much money. His dedication allowed him to become a physician and care for the poor regardless of their ability to pay. Serving as a voice for those with psychiatric disorders, he devoted his medical career to destigmatizing mental illness. He fought on behalf of those who couldn’t fight for themselves, including people suffering from schizophrenia who were chained down in institutions because society did not understand their illness. Because having mental illness often meant living in extreme poverty, Rush would often serve his patients without being paid. But that didn’t stop him. Considered the forefather of psychiatry, he held strong views on equality, even publicly calling for the abolition of slavery, declaring it a crime. Dr. Rush would later become one of five physician signers of the Declaration of Independence. He was at George Washington’s side during the crossing of the Delaware, and he treated injured soldiers behind enemy lines. His duty to serve the sick and injured of society rose above any other allegiance. Dr. Rush was among the first to call for equal rights for women, free education and health care for the poor, citywide sanitation facilities, an end to child labor, universal public education, prison reform, and an end to capital punishment. He was highly critical of tobacco smoking and was known to call out physicians when he observed greed and incompetence among them.
Of all the signers of the Declaration, Rush would become the Founding Father most interested in diversity issues, stemming from his views on equality.3 After his death, Thomas Jefferson said in a letter that he knew no one “more benevolent, more learned, of finer genius, or more honest.” In comparing Benjamin Rush to Benjamin Franklin, President John Adams said, “Rush has done infinitely more good to America than Franklin. Both had deserved a high Rank among Benefactors to their Country and Mankind; but Rush by far the highest.”
As we today struggle to address the issues in health care, doctors and other medical care professionals must remember the compassion that first drew us into the field. We need to remember the torch that Hopkins, Dandy, Sabin, Salk, and Rush passed on to us. Through their example and teachings, they bequeathed to us a mission of a healing profession that values equality. Regardless of circumstances, their mission was to take care of a fellow human being when they were vulnerable, and to be their advocate.
Honesty in Medicine
The contrast between the money games of medicine and the mission of our predecessors who worked so hard to earn the public trust couldn’t be sharper. Today, health care’s cost crisis has become an enormous blame game. People blame the arrogance of a Martin Shkreli and the gamesmanship of a Mylan Pharmaceuticals. People blame central line infections and surgical site infections. After all, it’s easy to blame bacteria. These are easy targets. The problem is that these factors are minor compared to the major structural issues of health care’s entrenched stakeholders.
People blame doctors, hospitals, payers, pharma, device companies, and even patients for not taking better care. But the money games are so established and the revenue stream they produce is so steady that experts don’t want to discuss altering the business model. But every one of us in health care, every stakeholder, needs to look inward and address the waste in our own backyard.
After seeing so clearly that commonsense transparency reforms are needed to make health care affordable, I’m amused when I hear so-called health care experts blame one another for high prices. 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. Experts are afraid to upset their bosses, who may promote them to leadership someday, or they fear upsetting stakeholders, who may pay their speaking fees. But a critical view of the whole ecosystem is exactly what we need. I’ve met so many people who speak on condition of anonymity about the waste in the system. At the same time, I’ve met health care minds unbeholden to the stakeholders. Some bold experts are unafraid to speak up. We need more honest critiques of the massive system.
We are at a critical moment in our nation’s history. Delivering health care can be much more democratic, more methodologically honest, and more transparent.
A Call to Action
Health care is perhaps today’s most divisive, territorial political issue. But many of the needed solutions are not partisan; they’re American. We are at a pivotal juncture. Spending on health care threatens every aspect of American society. The time for commonsense reform has arrived. All of us can play a part in driving badly needed reforms, both in the marketplace and in the policy world. As Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
One simple thing you can do: ask for a price every time you are considering a medical service. One hospital administrator I met during this journey told me that his hospital created a clear pricing sheet for delivering a baby, broken down for an uncomplicated vaginal delivery, for a C-section, for the epidural, and even for the car seat you can take home. That’s a milestone event. That hospital decided to adopt fair and transparent pricing for baby delivery services because people asked. Most of health care can behave like any other marketplace in any other industry: it responds to customer demands for non-urgent services, which account for most health care services. A restaurant owner will be more likely to switch to organic foods if every customer asks the waiter “Is this food organic?” It’s the same with hospitals. They respond to people who consistently ask good questions before choosing where to get their medical care.
As a society, we should embrace a basic set of patient rights, including a right to obtain a timely quote for a shoppable medical service. Lawmakers should look at the price transparency trails blazed by Florida, New Hampshire, and Maine. The prerequisite of any free market is viewable pricing information—not just inflated charges, but the actual amounts of settled bills. New policies should ensure a level playing field to make the free market functional again, to cut the waste and restore competition to the marketplace.
Physicians and hospitals can join the grassroots groundswell of physicians working toward a fair and functional health care system. The national Choosing Wisely4 project, our Hopkins-based Improving Wisely5 project, and the High Value Practice Academic Alliance6 represent a few simple ways to get involved. Developing sound measures of appropriateness across thousands of areas of medical care requires input from clinicians on the front lines of medicine.
Hospital leaders should consider the tremendous demand in the market for increased honesty in health care. That includes being up-front about prices and making themselves available to discuss bills. Everyday Americans and business leaders are hungry for this kind of square dealing. Hospitals that respond to this demand will distinguish themselves as leaders in the health care landscape of the future. The market will soon reward hospitals that offer quality and price transparency. Dr. Keith Smith of the Surgery Center of Oklahoma and other leaders of the free market medical movement have demonstrated how transforming a medical center to one that embra
ces transparency is not only feasible, but profitable.
Finally, billing quality is medical quality. Hospitals should be evaluated on their billing quality in patient navigation tools and hospital rankings. And when a hospital goes overboard to sue masses of low-income patients, going after their paychecks and putting liens on their homes, concerned citizens like you and I should respond by contacting the hospital’s board of trustees to remind them that hospitals were built to be a safe haven for the sick and injured regardless of one’s race, creed, or ability to pay. No patient should be at home sick and scared of going to a hospital for fear of price gouging. Reminding health care leaders of medicine’s great public trust is the start of rebuilding a more honest and compassionate health care system.
So, the next time you have a conversation about health care, use a patient-centered vocabulary. By calling things what they are, we can avoid downplaying the crisis at hand. As Americans, we need to say enough is enough. Transparency’s time has come. And for the sake of our patients, health professionals should lead this charge. It’s central to our great medical heritage. As witnesses to birth, sickness, and death, we know that all humans are created equal and deserve to be treated with fairness and dignity.
Acknowledgments
A big thank-you to the Halsted surgery residents at Johns Hopkins who model patient-centered care better than anyone I know. I love you guys. And to my surgical mentors John Cameron, Andrew Warshaw, Charles Yeo, Robert Higgins, and Julie Freischlag. Thanks to my book club: Peter Hill, Redonda Miller, Stephen Sisson, Karen Davis, Daniel Brotman, Deb Baker, and Diana Ramsay for your incredible collegiality and teamwork that keeps work fun.