The Price We Pay

by Marty Makary

  Thank you to Margeaux Van Horn and Tara Kennedy for your work on the book and coordinating with my crazy schedule and to my editors Marshall Allen, who helped me shape the book and encouraged me to go out into the field, and Nancy Miller, who believed deeply in this massive project and brought it to life. Thank you to the giant scholars of quality from whom I have learned a lot, Don Berwick, Bryan Sexton, Bruce Hall, Clifford Ko, Peter Pronovost, Atul Gawande, Maureen Bisognano, and Albert Wu. And special thanks to Elliot Fishman, Pamela Johnson, Josh Sharfstein, Tom Coburn, Katy Talento, John Hundt, Cynthia Fisher, Keith Lemer, Nathan Bays, Brian Blase, Zubin Damania, Peter Attia, Wendell Primus, Kavita Patel, Dick & Becky Cowart, Claire Haltom, Bill Frist, Jim Cooper, Annie Lamont, Angela Profeta, Danielle Lavey, Kathryn Weismantel, Mike Pykosz, Ryan Lee, Jason Davis, Adam Russo, Perla Ni, Suchi Saria, Lanalee Araba Sam, Nirav Shah, Chris Chen, Lydia Vogt, Andrew Ibrahim, Larry Van Horn, David Silverstein, Jeffrey Sachs, Robin Gelburd, Dean Sicoli, and Charlene Frizzera for your expertise and moral support.

  Notes

  Preface

    1.   M. H. Katz, D. Grady, and R. F. Redberg, “Undertreatment Improves, but Overtreatment Does Not,” JAMA Internal Medicine 173, no. 2 (2013): 93.

    2.   E. S. Huang, “Potential Overtreatment of Older, Complex Adults with Diabetes,” Journal of the American Medical Association 314, no. 12 (2015): 1280–81.

    3.   S. J. Katz, R. Jagsi, and M. Morrow, “Reducing Overtreatment of Cancer with Precision Medicine: Just What the Doctor Ordered,” Journal of the American Medical Association 319, no. 11 (2018): 1091–92.

    4.   S. Wheeler, American Society of Clinical Oncology Quality Care Symposium, October 10, 2018, Phoenix, AZ.

    5.   A. W. Mathews, “Employer-Provided Health Insurance Approaches $20,000 a Year,” Wall Street Journal, October 3, 2018.

    6.   N. Sood, A. Ghosh, and J. Escarce, “Health Care Cost Growth and the Economic Performance of U.S. Industries,” HSR: Health Services Research, June 9, 2009.

  Chapter 1: Health Fair

    1.   “$37 Million Settlement Reached in Unnecessary Heart Stent Case,” WJZ CBS Baltimore, April 7, 2014.

    2.   The guidelines say there is not sufficient evidence to show the screening is beneficial for patients without symptoms. Final Recommendation Statement: Peripheral Arterial Disease (PAD) and CVD in Adults: Risk Assessment with Ankle Brachial Index. U.S. Preventive Services Task Force, December 2016.

    3.   A. Andras and B. Ferket, “Screening for Peripheral Arterial Disease,” Cochrane Database of Systematic Reviews, 2014, issue 4, Art. No. CD010835, doi:10.1002/14651858.CD010835.pub2.

    4.   S. Wheeler, American Society of Clinical Oncology Quality Care Symposium, October 10, 2018, Phoenix, AZ.

    5.   P. Salminen et al., “Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial,” Journal of the American Medical Association 313, no. 23 (2015): 2340–48.

    6.   J. F. Svensson et al., “Nonoperative Treatment with Antibiotics versus Surgery for Acute Nonperforated Appendicitis in Children: A Pilot Randomized Controlled Trial,” Annals of Surgery 261, no. 1 (2015): 67–71.

    7.   H. C. Park et al., “Randomized Clinical Trial of Antibiotic Therapy for Uncomplicated Appendicitis,” British Journal of Surgery 104, no. 13 (2017): 1785–90.

    8.   P. Salminen et al., “Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial,” Journal of the American Medical Association 320, no. 12 (2018): 1259–65.

    9.   S. Di Saverio et al., “The NOTA Study (Non Operative Treatment for Acute Appendicitis): Prospective Study on the Efficacy and Safety of Antibiotics (Amoxicillin and Clavulanic Acid) for Treating Patients with Right Lower Quadrant Abdominal Pain and Long-term Follow-up of Conservatively Treated Suspected Appendicitis,” Annals of Surgery 260, no. 1 (2014): 109–17.

  10.   D. A. Talem, “Shared Decision Making in Uncomplicated Appendicitis: It Is Time to Include Nonoperative Management,” Journal of the American Medical Association 315, no. 8 (2016): 811–12.

  11.   Dr. Edward Livingston, deputy editor of the Journal of the American Medical Association, quoted in Steven Reinberg, “Appendicitis Can Often Be Treated with Antibiotics,” HealthDay, June 16, 2015.

  12.   L. S. Lim et al., “Atherosclerotic Cardiovascular Disease Screening in Adults: American College of Preventive Medicine Position Statement on Preventive Practice,” American Journal of Preventive Medicine 40, no. 3 (2011): 380–81.

  13.   W. E. Bruhn et al., “Cardiovascular Screenings at United States Churches” (forthcoming), Johns Hopkins University.

  14.   C. W. Hicks et al., “Race and Socioeconomic Disparities Associated with Peripheral Vascular Interventions for Claudication” (forthcoming), Johns Hopkins University, 2020.

  15.   C. W. Hicks et al. “Overuse of Early Peripheral Vascular Interventions for Claudication,” Journal of Vascular Surgery, 2019.

  Chapter 2: Welcome to the Game

    1.   B. D. et al., “Association of Hospital Prices for Coronary Artery Bypass Grafting with Hospital Quality and Reimbursement,” American Journal of Cardiology 117, no. 7 (2016): 1101–06.

    2.   T. Xu et al., “Variation in Emergency Department Excess Charges in the United States,” JAMA Internal Medicine, May 2017.

    3.   J. Harris, “I Tried to Find Out How Much My Son’s Birth Would Cost. No One Would Tell Me,” Vox, May 5, 2016.

    4.   A. W. Mathews, “Behind Your Rising Health-Care Bills: Secret Hospital Deals That Squelch Competition,” Wall Street Journal, September 22, 2018.

    5.   J. Li, mock-up cover art for “Why Childbirth in the U.S. Is More Expensive than Other Countries,” Axios, October 12, 2018.

    6.   NORC at the University of Chicago, “New Survey Reveals 57 Percent of Americans Have Been Surprised by a Medical Bill,” ScienceDaily, August 30, 2018.

    7.   Ibid.

    8.   The New Mexico Office of Superintendent of Insurance and the University of New Mexico RWJF Center for Health Policy conducted the 2017 survey.

    9.   T. Xu et al., “Variation in Emergency Department Excess Charges in the United States.”

  10.   S. Wheeler, American Society of Clinical Oncology Quality Care Symposium, October 10, 2018, Phoenix, AZ.

  11.   A. W. Mathews, “Employer-Provided Health Insurance Approaches $20,000 a Year,” Wall Street Journal, October 3, 2018.

  12.   B. Herman, “Hospital Prices Are All Over the Board,” Axios, August 30, 2018.

  13.   J. A. Sakowski et al., “Peering into the Black Box: Billing and Insurance Activities in a Medical Group,” Health Affairs 28, no. 4 (2009): w544.

  14.   Xu T. et al., “The Potential Hazards of Hospital Consolidation: Implications for Quality, Access, and Price,” Journal of the American Medical Association 314, no. 13 (2015): 1337–38.

  15.   M. A. Makary and G. Bai, “Revealing the Real Prices Insurers Pay Can Save Health Care,” STAT News, May 2, 2019.

  16.   A. W. Mathews, “Behind Your Rising Health-Care Bills: Secret Hospital Deals That Squelch Competition.”

  17.   A. Mehta et al., “The Impact of Price Transparency for Surgical Services,” American Surgeon 84, no. 4 (2018): 604–608.

  18.   Federal Trade Commission, “Complying with the Funeral Rule,” https://www.ftc.gov/tips-advice/business-center/guidance/complying-funeral-rule.

  Chapter 3: Carlsbad

    1.   B. DiJulio et al., “Data Note: Americans’ Challenges with Health Care Costs,” Henry J. Kaiser Family Foundation, March 2, 2017.

    2.   West Health Institute and the NORC at the University of Chicago
Report, “Americans Fear Crippling Medical Bills More than Illness,” HealthDay, March 2018.

    3.   United States Federal Reserve Bank Board of Governors, “Report on the Economic Well-Being of U.S. Households in 2017,” May 2018.

    4.   T. Tepper, “Most Americans Don’t Have Enough Savings to Cover a $1K Emergency,” Bankrate, January 18, 2018.

    5.   United States Department of Labor, Wage and Hour Division, https://www.dol.gov/whd/regs/compliance/whdfs30.htm.

  Chapter 4: Two Americas

    1.   W. E. Bruhn et al., “Prevalence and Characteristics of Virginia Hospitals Garnishing Wages for Unpaid Medical Bills,” Journal of the American Medical Association (2019).

    2.   Ibid.

    3.   United States Department of Labor: May 2017 National Occupational Employment and Wage Estimates United States.

    4.   T. Xu et al., “Variation in Emergency Department Excess Charges in the United States,” JAMA Internal Medicine (May 2017).

    5.   IRS Revenue Ruling 56-185, 1956-1 C.B. 202.

    6.   IRS Revenue Ruling 69-545, 1969-2 C.B. 117, which remains the current standard.

  Chapter 5: The Ride

    1.   D. Rosato, “Air Ambulances: Taking Patients for a Ride,” Consumer Reports, April 6, 2017.

    2.   K. Reece, “Snake Bite Victim Gets $30K Helicopter Bill,” WFAA, ABC channel 8, Dallas, August 11, 2017.

    3.   G. A. Vercruysse et al., “Overuse of Helicopter Transport in the Minimally Injured: A Health Care System Problem That Should Be Corrected,” Journal of Trauma and Acute Care Surgery 78, no. 3 (2015): 510–15.

    4.   Rosato, “Air Ambulances.”

    5.   F. A. Habib et al., “Probable Cause in Helicopter Emergency Medical Services Crashes: What Role Does Ownership Play?” Journal of Trauma and Acute Care Surgery 77, no. 6 (2014): 989–93.

  Chapter 6: Woman in Labor

    1.   D. L. Riddle et al., “Use of a Validated Algorithm to Judge the Appropriateness of Total Knee Arthroplasty in the United States: A Multicenter Longitudinal Cohort Study,” Arthritis and Rheumatology 66, no. 8 (2014): 2134–43.

  Chapter 7: Dear Doctor

    1.   American College of Mohs Surgery, “History of Mohs Surgery,” https://www.mohscollege.org/about/about-mohs-surgery/history-of-mohs-surgery.

    2.   L. P. Casalino et al., “US Physician Practices Spend More than $15.4 Billion Annually to Report Quality Measures,” Health Affairs 35, no.3 (2016): 401–406.

    3.   J. Albertini et al., “Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse,” JAMA Dermatology, published online May 5, 2019.

    4.   I. Ayres, S. Raseman, and A. Shih, “Evidence from Two Large Field Experiments That Peer Comparison Feedback Can Reduce Residential Energy Usage,” NBER Working Paper No. 15386, September 2009.

    5.   www.improvingwisely.com.

  Chapter 8: Scaling Improvement

    1.   Social Science and Medicine 211 (August 2018).

    2.   K. Kaczmarski et al., “Surgeon Re-excision Rates after Breast-Conserving Surgery: A Measure of Low-Value Care,” Journal of the American College of Surgeons 228, no. 4 (2019): 504–12.

    3.   P. Wang et al., “Same-day Versus Different-day Elective Upper and Lower Endoscopic Procedures by Setting,” JAMA Internal Medicine, published online May 13, 2019.

    4.   M. A. Makary et al., “Patient Safety in Surgery,” Annals of Surgery 243, no. 5 (2006): 628–35.

    5.   M. A. Makary et al., “Operating Room Briefings: Working on the Same Page,” Joint Commission Journal on Quality and Patient Safety 32, no. 6 (2006): 351–55.

    6.   M. A. Makary et al., “Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder,” Journal of the American College of Surgeons 202, no. 5 (2006): 746–52.

    7.   M. A. Makary et al., “Operating Room Briefings and Wrong-site Surgery,” Journal of the American College of Surgeons 204, no. 2 (2007): 236–43.

    8.   M. A. Makary et al., “Patient Safety in Surgery,” Annals of Surgery 243 (2006): 628–35.

    9.   WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Available online at http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf;jsessionid=4C0514716CEEBE8D819E2BFB223E7638?sequence=1.

  10.   American Society for Gastrointestinal Endoscopy, “Understanding Polyps and Their Treatment,” https://www.asge.org/home/for-patients/patient-information/understanding-polyps.

  11.   J. A. Sparano et al., “Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer,” New England Journal of Medicine 379, no. 2 (2018): 111.

  Chapter 9: Opioids like Candy

    1.   J. Katz, “Drug Deaths in America Are Rising Faster than Ever,” New York Times, June 5, 2017.

    2.   H. Hedegaard et al., “Drug Overdose Deaths in the United States, 1999–2016,” NCHS Data Brief No. 294, December 21, 2017.

    3.   Hill et al., “Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures,” Annals of Surgery 256, no. 4 (2017): 709–14.

    4.   H. Overton et al., “Opioid Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus,” Journal of the American College of Surgeons 227, no. 4 (2018): 411–18.

    5.   www.solvethecrisis.org.

    6.   M. A. Makary, “How Doctors Can Stop the Opioid Crisis at Its Source,” USA Today, August 4, 2017.

  Chapter 10: Overtreated Patients like Me

    1.   B. Lazarus et al., “Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease,” JAMA Internal Medicine 176, no. 2 (2016): 238–46.

    2.   T. Carr, “Too Many Meds? America’s Love Affair with Prescription Medication,” Consumer Reports, August 3, 2017.

    3.   Ibid.

    4.   M. Ellenbogen et al., (forthcoming), Johns Hopkins University, 2019.

    5.   M. Favro, “Doctor Agrees with Steve Kerr’s Advice to Avoid Back Surgery,” NBC Bay Area, April 24, 2017.

    6.   Washington Health Alliance, “New Study Finds Hundreds of Thousands of Washington Patients Receive Unnecessary Tests, Procedures, and Treatments,” https://wahealthalliance.org/new-study-finds-hundreds-of-thousands-of-washington-patients-receive-unnecessary-tests-procedures-and-treatments/.

    7.   K. R. Chhabra et al., “Surgical Decision Making: Challenging Dogma and Incorporating Patient Preferences,” Journal of the American Medical Association 317, no. 4 (2017): 357–58.

    8.   High Value Practice Academic Alliance, www.hvpaa.org.

    9.   H. Lyu et al., “Overtreatment in the United States,” PLoS ONE 12, no. 9 (2017) e0181970.

  10.   M. A. Makary et al., “A Call for Doctors to Recommend Antibiotic-Free Foods: Agricultural Antibiotics and the Public Health Crisis of Antimicrobial Resistance,” Journal of Antibiotics 71, no. 8 (2018).

  11.   H. S. Ahn et al., “Korea’s Thyroid-Cancer ‘Epidemic’—Screening and Overdiagnosis,” New England Journal of Medicine 371, no. 19 (2014): 1765.

  12.   S. Park et al., “Association between Screening and the Thyroid Cancer ‘Epidemic’ in South Korea: Evidence from a Nationwide Study,” British Medical Journal, November 30, 2016.

  13.   New England Journal of Medicine commentary by Dr. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice and Dr. Hyeong Sik Ahn of Korea University.

  14.   H. S. Ahn et al., “South Korea’s Thyroid-Cancer ‘Epidemic’—Turning the Tide,” New England Journal of Medicine 373, no. 24 (2015): 2389.

 
15.   S. Vaccarella et al., “Worldwide Thyroid Cancer Epidemic? The Increasing Impact of Overdiagnosis,” New England Journal of Medicine 375, no. 7 (2016): 614–17.

  16.   Right Care series, The Lancet: https://www.thelancet.com/series/right-care. S. Brownlee, K. Chalkidou, J. Doust, A. G. Elshaug, P. Glasziou, I. Heath, S. Nagpal, V. Saini, D. Srivastava, K. Chalmers, D. Korenstein, “Evidence for Overuse of Medical Services around the World,” Lancet 390, no. 10090 (2017): 156–68.

  Chapter 11: Starting from Scratch

    1.   F. Lambert, “Virginia Auto Dealers Are Suing Tesla and the State to Stop the Automaker from Opening a Store,” Electrek, March 10, 2016.

    2.   A. Suderman, “Tesla Representative Booted from Auto Dealers’ Board,” Associated Press, January 24, 2018.

    3.   Medallia, Net Promoter Score: https://www.medallia.com/net-promoter-score/.

    4.   Kaiser Family Foundation, “An Overview of Medicare,” April 2016, retrieved from http://www.kff.org/medicare/issue-brief/an-overview-of-medicare/.

  Chapter 12: Disruption

    1.   Centers for Medicare and Medicaid Services, “Emergency Medical Treatment and Labor Act,” https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/.

    2.   J. Curtis et al., “What Does the Affordable Care Act Say about Hospital Bills?” Hospital Accountability Project, June 15, 2015, https://www.communitycatalyst.org/resources/publications/document/CC-ACAHospitalBillsReport-F.pdf?1434480883.

  Chapter 13: Buying Health Insurance

    1.   C. Isidore and M. Egan, “Wells Fargo under Siege,” CNNMoney, September 13, 2016.

    2.   M. Egan, “Workers Tell Wells Fargo Horror Stories,” CNNMoney, September 9, 2016.

    3.   “Fed Up with Rising Costs, Big US Firms Dig into Health Care,” Reuters, June 11, 2018.

    4.   Employer Health Benefits 2018 Annual Survey, Kaiser Family Foundation, 2018.