Medical Madness
If you are feeling good about life, healthy, surrounded by family and friends, enjoying leisure, or work, or both, it’s time to read a book. I have a few to recommend. Perhaps you’d like to start with a couple of easy reads: Robert M Kaplan’s More than Medicine (Harvard UP, 2019), or Nortin Hadler’s The Citizen Patient (UNC Press, 2013). Kaplan explores why insufficient attention is being given to preventive health care, and Hadler reminds us that medicine is, fundamentally about the human relationship between the doctor and the patient. Oops, I might have forgotten to mention the subtitle of Kaplan’s book was “the broken promise of American health”, and Hadler’s was “reforming health care for the sake of the patient not the system”. Anyway, I’ve softened you up, so let’s get a little more serious. How about Elisabeth Rosenthal next, An American Sickness (Penguin, 2017), on the “money chase” behind the medical system; or, one of my favourites, Katherine Eban’s Bottle of Lies (Ecco, 2019), a devastating exposé of fake generic drug manufacturing across the world. Not quite enough yet? Let’s end our recommended reading list with Caroline Elton’s Also Human (Basic Books, 2018), a moving study of distressed and sometime psychologically disturbed medical practitioners.
In different ways, these five books reveal how the pursuit of profits has warped and wrecked the health care system in the US, with warnings signs as to how the same distortions could easily work their way in to medical care in Australia and the UK. You are probably aware of much these books reveal, though the details are horrific (read these books during the day, please, not at night). At the risk of repetition, I want to go over some of the more dreadful features of what they cover, then explore how this relates to the lives of medical practitioners, and end with asking ‘what can be done?’. I am going to talk about the situation here in the US, but please let me reiterate, the same issues are slowly but surely infecting systems in Australia and the UK.
My guide in this is Marty Makary, and since I am going to keep borrowing from his book, The Price We Pay, (Bloomsbury, 2019), the best way to do this is to say, right at the start, “thanks Marty, and I hope it sells more of your outstanding book”, because this is the one everyone should read. I’ll start quoting, right away: “Dr. Makary is a Johns Hopkins surgeon and Professor of Health Policy & Management. He is a leading voice for physicians writing for the Wall Street Journal and USA Today and is a member of the National Academy of Medicine. He is the founder of Restoring Medicine, an advocacy effort to help people who can’t afford their medical bills. Dr. Makary also serves as executive director of Improving Wisely, a national physician collaboration to reduce unnecessary medical care and lower health care costs. His current research focuses on the appropriateness of medical care, administrative waste, price and quality transparency, and the impact of health care costs on low-income populations.”
The Price We Pay begins with an extraordinary but true account of community health fairs held in churches in the USA. The scene appears so altruistic, with medical providers examining older under-served members of the congregation, mainly those who are poor or from minority groups. At the church Makary visited, staff from a cardiology group were testing blood flow in each person’s legs. What the people being tested didn’t know was this test is usually given to patients with serious symptoms, like crippling leg pain. At the fair, several people were referred on for ultrasound testing or other procedures, and even leg artery surgery, frequently when none of this was needed. “Do you have leg pains?” a potential patient would be asked. Gently nudged, many said “yes”, even when the pain was either minor or non-existent; “Let’s fix this before it gets worse.” Once on the cardiology conveyor belt, the patients would incur some major costs: for many, payment would be through Medicare; for any younger people there, through a health insurance provider; for some, out of their own pocket, possibly having to cover heavy personal contributions. Most of the time ‘we’ are paying for this, through our contributions to Medicare or our insurance policy payments. Welcome to the medical-industrial complex (MIC).
What is the MIC? It has three major components. First, the management of health care organisations, including hospitals, specialised health care centres and private practices, is increasingly undertaken by business staff rather than medical practitioners, with a priority on increasing profitability. Second, manufacturers of medical devices fund medical education programs, physicians and hospitals directly to ensure adoption of their devices. Third, with increasing ingenuity drug companies support and encourage practitioners to use their products, while simultaneously advertising them directly to the public. The system has kickbacks galore.
Of course, you might ask, where does the money come from? Makary explains this as ‘the game’. It starts like this. When you go to see a medical practitioner, you might ask “how much is this going to cost?”. Almost invariably, that simple piece of information will prove hard to get, unless you are asking at your local family practice. The reasons will be plentiful, and all boil down to “we’ll tell you once we’ve dealt with you”; the implication being the final price will be determined by what happens. Actually, what happens mainly depends on your medical cover.
If you are aged over 65 years, and are enrolled in Medicare, most of the costs will be covered by Medicare, unless you are unlucky enough to require some procedures or tests that are excluded. If you are younger, but have some form of medical insurance, and if you are seeing a practitioner who is ‘in-network’, then your insurer will have negotiated a rate for the procedures involved: you may have to pay some figure above that, though these additional expenses are usually limited by a capped ‘deductible’. In-network refers to a practitioner that has been signed into your insurance company’s total network of doctors; a ‘deductible’ is just that, a level of expense you will have to meet before the insurance company covers most areas of cost. If the practitioner is out of the network, the charges, and the deductible to be met can rapidly escalate. Finally, if you are not covered by insurance, you can be charged the full amount.
But what is the full amount? As Makary explains, there is no limit on the fees a practitioner or hospital can invoice. As one person told him, when querying a bill for a friend “The law allows us to charge whatever we want. If we want to charge a million dollars, she has to pay it”. Hospitals and practices can and do demand payment of outstanding costs, however high, and however impossible to be met. They resort to debt collection measures, and may get a court order to garnish a person’s wages (taking a court agreed amount every week or month, often leaving people close to the breadline). Makary looked into the situation in one state, Virginia, and found that 37% of hospitals there sued patients for overdue treatment costs, accounting for 20,000 lawsuits in just one year. These are likely to be the same hospitals who charge very high fees, supposedly to ‘cover the costs of treating poor patients’; except, they’re suing the poor!
And the ‘game’. It works like this. Procedures have a ‘sticker price’, like the sticker price you see on a car in a used car lot; although, remember, you don’t see the sticker price until after the procedure. Medicare has negotiated a discounted rate it will pay for procedures (but the rate can differ by practitioner and hospital); insurance companies have also negotiated a discounted rate (often heavily discounted). Remember, if you have insurance, the insurer will pay the agreed rate, but you may be charged a further contribution. If you’re not insured, you can be charged the sticker price! These are the fees quoted in stories. Just to give a sense of what this is like, in 2016 Medicare paid $13,000 for a standard joint replacement surgery. Makary’s team found sticker prices as high as $135,000, and these have continued to increase year on year.
Each year, hospitals or practitioners often justify increasing sticker prices on the basis the insurance companies are demanding a bigger discount, in order to make a profit. So the providers have to charge more so they can make a profit, too. It’s a vicious circle. [i] In order to play this game, hospitals need an ever-growing administrative bureaucracy: Makary reports one study which found that for every 10 doctors employed, there were seven staff (non-clinical, obviously) working on billing and insurance. That leaves on one side the time spent by those same clinical practitioners coding every single activity they undertook.
The first half of the book is devastating. I could go on to summarise chapters about charging unbelievably high and unacceptable costs for transport, especially helicopters for more remote areas. Or overtreating patients to increase the revenue for each referral. Or the over-prescribing of expensive drugs, including those at the heart of the current opioid crisis. Read his book, and the others I mentioned, but please be warned, only if you feel strong enough: it’s horrific.
However, before we examine the proposals Makary puts forward to deal with an MIC out of control, this might be the time to look at the other side of the issue, the practitioners themselves. To do that, let’s imagine the careers of Mark, a recently retired surgical oncologist, and Jean, a family practitioner with a particular focus on obstetrics and gynecology. Mark came from a medical family: his father a pediatrician, his mother a pharmacist. With an aptitude for science, he took an undergraduate degree specialising in biology and chemistry, along with other science and liberal arts courses. With a well-rounded resumé, and a high score on MCAT, he was admitted to a top tier medical school. His parents didn’t push him, but they were pleased. Jean’s path was a little different. She came from a white-collar family, and in her undergraduate degree explored law, computer science and linguistics, before settling down to take traditional science subjects in her last two years. Not feeling very confident, she took MCAT, did better than she’d anticipated, and entered a good medical school. Her parents were proud of her.
Once in Medical School, Mark was focussed. By his final year, he decided he wanted to be a surgeon, attracted to the life-saving role of a surgical oncologist. He landed a top residency in a leading cancer hospital; after six exhausting years, he passed his licensing exams. He was offered a position in a comprehensive cancer centre on the west coast. With massive debts to repay, it took him another eight years to be clear of all his obligations, and enjoy an affluent lifestyle with his wife and two growing children, initially on a salary of $300,000 a year; later it grew to $500,000. Jean was less clear about specialising, hovering between obstetrics and gynecology, family medicine, and emergency care. She eventually obtained a residency in a smaller community hospital, allowing her to pursue her broad interests. After five years, she completed her licensing examinations and was appointed a family practitioner in a medium sized medical centre, soon earning. $150,000 a year. Ten years later, debt free, she was on $240,000. Familiar stories: years of training, big loans, and hard work to be debt free and enjoying life.
However, one day, at the age of 49, Mark walked out after surgery, left the hospital, went to a local bar and started drinking. By the time his wife tracked him down, he was paralytically drunk. He refused to go back to work, and each day when his wife went to work, he went out, got drunk, and had to be collected. Six months later, he had stopped drinking, but told his psychologist that he would never work in medicine again. When asked why not, he kept repeating the same comment, “I was just a money-making machine for the hospital; I wanted to save people”. Yes, that’s a familiar cry: it’s called moral injury. [ii] The MIC crushes doctors’ ideals, their lives taken up with device company salespeople offering new surgical tools, completing computerized checklists, allocating treatment codes, while hardly knowing the patient in the operating theatre. Some just take the money, many feel disillusioned. Jean was luckier. She, too, had to fend of drug and device salespeople; practice reviews commented on her low (‘not satisfactory’?) level of specialist referrals. Slowly, she reduced her workload, seeing a group of loyal patients who wanted her and no-one else. She’d learnt to hide, and was able to enjoy her home life, with her high school teacher husband, and their two children. [iii]
The MIC exploits patients and doctors. Patients are over-charged, over serviced, their payments fattening the salaries of administrators, salespeople, and medical company executives. Doctors are ground down to the point where their value is measured in the number and value of the codes for services they generate each day. The MIC is exactly as it sounds, a big business complex, with patient care almost incidental. I’m sure you knew this. Today, the critical issue is whether anything can be done to constrain and change a system getting further and further out of control.
Makary offers some proposals. Several are directed at practitioners, encouraging them to return to a patient-centred approach to health care, taking their eyes away from the computer screen, reducing unnecessary testing and other interventions. Others are aimed at putting greater transparency into the system, clarifying the real costs to be charged for procedures up front, as is routinely the case in health services in other countries. A major issue is medical insurance: Makary advocates breaking up some of the huge groups, re-establishing competition, and eliminating kick-backs to brokers. He also wants to eliminate price gouging by pharmacy benefits managers, who sell deals on pharmaceuticals with customer prices being increased by a 1000% or more; here, as elsewhere, the need is for greater visibility, so patients can see drug costs from alternative suppliers. Finally, he wants kick-backs and other deals for purchasing organisations to be eliminated. Underlying all his proposals is one constant theme: the need for complete transparency throughout the system, so everyone can see what is happening.
Eventually, a system out of control blows up, but eventually can be a long time coming. For the sake of frightened patients, terrified they’ll lose their savings and their homes, and for desperate, overworked doctors losing their ideals as they find themselves complicit in an extortion game, it’s time to rip apart the corrupt medical-industrial complex. Stop medical madness, right now.
[i] Leemore Dafny has published compelling research to show this: See Evaluating the Impact of Health Insurance Industry Consolidation, Commonwealth Fund, November 2015, and Testimony on Health Care Consolidation to the House Subcommittee on Oversight and Investigation, House Committee on Energy and Commerce, 2/14/ 2018.
[ii] See The Lancet, 2 November,2019: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32669-8/
[iii] All this, and so much more is discussed in Caroline Elton’s Also Human. These are my examples.
