An American Sickness

Elisabeth Rosenthal, MD, former ER physician and subsequently New York Times reporter of lengthy, considerable note, is now Editor-in-Chief at Kaiser Health News.

Elisabeth Rosenthal, Editor-in-Chief, joined KHN in September 2016 after 22 years as a correspondent at The New York Times, where she covered a variety of beats from health care to environment to reporter in the Beijing bureau. While in China she covered SARS, bird flu and the emergence of HIV/AIDS in rural areas. Libby’s 2013-14 series “Paying Till it Hurts” won many prizes for both health reporting and its creative use of digital tools. Her book, “An American Sickness: How Healthcare Became Big Business And How You Can Take it Back,” is being published by Penguin Random House in April 2017. She is a graduate of Stanford University and Harvard Medical School and briefly practiced medicine in a New York City emergency room before converting to journalism.

I am deep into her new book. A sobering, riveting, and at times infuriating read. I'm already well aware of of lot of what she writes, but it at once raises my BP and validates my own take on this morally untenable aspect of health care. I'm not crazy (or naive) after all.

Hashtag #anamericansickness.

The more I read, the more the word "Pultizer" repeatedly wafts up in my mind.

INTRODUCTION
Complaint: Unaffordable Healthcare
In the past quarter century, the American medical system has stopped focusing on health or even science. Instead it attends more or less single-mindedly to its own profits.

Everyone knows the healthcare system is in disarray. We’ve grown numb to huge bills. We regard high prices as an inescapable American burden. We accept the drugmakers’ argument that they have to charge twice as much for prescriptions as in any other country because lawmakers in nations like Germany and France don’t pay them enough to recoup their research costs. But would anyone accept that argument if we replaced the word prescriptions with cars or films?

The current market for healthcare just doesn’t deliver. It is deeply, perhaps fatally, flawed. Even market economists themselves don’t believe in it anymore. “It’s now so dysfunctional that I sometimes think the only solution is to blow the whole thing up. It’s not like any market on Earth,” says Glenn Melnick, a professor of health economics and finance at the University of Southern California.

Nearly every expert I’ve spoken with— Republican or Democrat, old or young, adherent of Milton Friedman or Karl Marx— has a theoretical explanation as to why the United States spends nearly 20 percent of its gross domestic product on healthcare— more than twice the average of developed countries. But each one also has a story of personal exasperation about the last time a family member or a loved one was hospitalized or rushed to an emergency room or received an incomprehensible, outrageous bill.

Stephen Parente, Ph.D., a health economist at the University of Minnesota and an adviser to John McCain in the 2008 presidential election, believes that studies overstate the excessive healthcare spending in the United States. But when he talks about the hospitalization of his elderly mother, his dispassionate academic tone shifts to one I’ve heard thousands of times, brimming with frustration:

There were a dozen doctors all sending separate bills and I couldn’t decipher any of them. They were all large numbers and the insurance paid a tiny fraction. Imagine if a home contractor worked this way? He estimates $ 125,000 for your kitchen and then takes $ 10,000 when it’s done? Would anyone ever renovate?

Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants. That’s how the healthcare market works. In no other industry do prices for a product vary by a factor of ten depending on where it is purchased, as is the case for bills I’ve seen for echocardiograms, MRI scans, and blood tests to gauge thyroid function or vitamin D levels. The price of a Prius at a dealership in Princeton, New Jersey, is not five times higher than what you would pay for a Prius in Hackensack and a Prius in New Jersey is not twice as expensive as one in New Mexico. The price of that car at the very same dealer doesn’t depend on your employer, or if you’re self-employed or unemployed. Why does it matter for healthcare?

We live in an age of medical wonders— transplants, gene therapy, lifesaving drugs, and preventive strategies— but the healthcare system remains fantastically expensive, inefficient, bewildering, and inequitable. Faced with disease, we are all potential victims of medical extortion. The alarming statistics are incontrovertible and well known: the United States spends nearly one-fifth of its gross domestic product on healthcare, more than $ 3 trillion a year, about equivalent to the entire economy of France. For that, the U.S. health system generally delivers worse health outcomes than any other developed country, all of which spend on average about half what we do per person.

Who among us hasn’t opened a medical bill or an explanation of benefits statement and stared in disbelief at terrifying numbers? Who hasn’t puzzled over an insurance policy’s rules of co-payments, deductibles, “in-network” and “out-of-network” payments— only to surrender in frustration and write a check, perhaps under threat of collection? Who hasn’t wondered over, say, a $ 500 bill for a basic blood test, a $ 5,000 bill for three stitches in an emergency room, a $ 50,000 bill for minor outpatient foot surgery, or a $ 500,000 bill for three days in the hospital after a heart attack?

Where is all that money going?

Rosenthal, Elisabeth (2017-04-11). An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (pp. 1-3). Penguin Publishing Group. Kindle Edition.

My contextual triangulation will eventually extend to a number of others I've previously cited. e.g.,

to wit,

In spite of the clear and recent data, the United States stumbles when addressing these social determinants of health. Although Americans do not like being mediocre in national health outcomes, they have been even less enthusiastic about facing the complex web of social conditions that produce and reinforce these outcomes. They continue to pay top dollar for hospitals, physicians, medications, and diagnostic testing yet skimp in broad areas that are central to health, such as housing, clean water, safe food, education, and other social services. It may even be that Americans are spending large sums for health care to compensate for what they are not paying in social services— and the trade-off is not good for the country’s health.

ROUGHLY FIVE YEARS AGO WE started thinking that there might be a connection between soaring health costs and meager social service spending, when we were musing about theoretical roots to the so-called health care paradox in the United States. To explore whether our hypothesis would hold up, we examined ten years of spending and health outcome data from thirty OECD countries that collected data using comparable methodologies. The results confirmed our suspicions.

Our comparative study, published in the academic literature in 2010, broadened the scope of inquiry about health and health spending to include spending on social services as a potential determinant of population-level health outcomes. For the purposes of our study, social services expenditures included public and private spending on old-age pension and support services for older adults, survivors benefits, disability and sickness cash benefits, family supports, employment programs (e.g., public employment services and employment training, unemployment benefits, supportive housing and rent subsidies), and other social services that exclude health expenditures. Health expenditures included public and private spending on curative care, rehabilitative care, long-term care, laboratory and diagnostic services, outpatient and preventive care, and public health services.

The study found that if we counted countries’ combined investment in health care and in social services, the United States was no longer spending the largest percentage of GDP— far from it. In 2007, for example, the United States devoted only 25 percent of gross domestic product to health and social services combined, while such countries as Sweden, France, Austria, Switzerland, and Denmark dedicated about 30 to 33 percent of their respective GDP to the combination. In 2007, while the United States ranked highest in health spending, it ranked only thirteenth in spending on health services and social services combined (see Figure 1.4).

Moreover, the study revealed that America was one of only three industrialized countries (the other two were Korea and Mexico) to spend the majority of its total health and social services budget on health care. On average in the OECD countries other than the United States, for every dollar spent on health care, an additional two dollars was spent on social services. Yet in the United States, for every dollar spent on health care, less than sixty cents was spent on social services. Most important, we found that less spending on social services relative to spending on health services was statistically associated with poorer health outcomes in key measures, such as infant mortality and life expectancy, and this result held even when the United States was removed from the analysis...

Bradley, Elizabeth H.; Taylor, Lauren A. (2013-11-05). The American Health Care Paradox: Why Spending More is Getting Us Less (Kindle Locations 420-448). PublicAffairs. Kindle Edition.

And, Steve Brill's compelling take on the evolution of our health care system (and which recounts his own frustrating experience with acute care), culminating in his analysis of the enactment of the ACA ("ObamaCare").

From its historical roots, to the mind-numbing complexity of the furiously lobbied final text of the legislation, to its stumbling implementation, to the bitter fights over it that persist to this day— the story of Obamacare embodies the dilemma of America’s longest running economic sinkhole and political struggle.

It’s about money: Healthcare is America’s largest industry by far, employing a sixth of the country’s workforce. And it is the average American family’s largest single expense, whether paid out of their pockets or through taxes and insurance premiums.

It’s about politics and ideology: In a country that treasures the marketplace, how much of those market forces do we want to tame when trying to cure the sick? And in the cradle of democracy, or swampland, known as Washington, how much taming can we do when the healthcare industry spends four times as much on lobbying as the number two Beltway spender, the much-feared military-industrial complex?

It’s about the people who determine what comes out of Washington— from drug industry lobbyists to union activists; from senators tweaking a few paragraphs to save billions for a home state industry to Tea Party organizers fighting to upend the Washington status quo; from turf-obsessed procurement bureaucrats who fumbled the government’s most ambitious Internet project ever to the selfless high-tech whiz kids who rescued it; and from White House staffers fighting over which faction among them would shape and then implement the law while their president floated above the fray to a governor’s staff in Kentucky determined to launch the signature program of a president reviled in their state.

But late in working on this book, on the night of that dream and in the scary days that followed, I learned that when it comes to healthcare, all of that political intrigue and special interest jockeying plays out on a stage enveloped in something else: emotion, particularly fear.

Fear of illness. Or pain. Or death. And wanting to do something, anything, to avoid that for yourself or a loved one...

Brill, Steven (2015-01-05). America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System (Kindle Locations 131-146). Random House Publishing Group. Kindle Edition.

There will be many more books to cite pertaining to this topic (the byzantine economics and policy perplex of health care). Stay tuned.

The Bradley/Taylor "Paradox" book is particularly interesting, putting per capita and aggregate "health" spending in a deservedly broader context. Think about the "Upstream."

BTW, see also my 2015 reporting on Steve Brill's excellent series "America's Most Admired Lawbreaker."
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I wrote my first blog post musing about our health care "system" on another of my blogs eight years ago. See "The U.S. health care policy morass."

Some reform advocates have long argued that we can indeed [1] extend health care coverage to all citizens, with [2] significantly increased quality of care, while at the same time [3] significantly reducing the national (and individual) cost. A trifecta "Win-Win-Win." Others find the very notion preposterous on its face. In the summer of 2009, this policy battle is now joined in full fury. I will try to add some constructive argument to the fray.

This likely will be a lengthy post that will accrue over time, given the complexity and importance of the topic, but,

FIRST, A PREFATORY STORY

In the mid-late 1990s, while caring for my terminally ill daughter in Hollywood, I recall reading that there were more MRI machines deployed in the Los Angeles area than in the entire nation of Canada, the inference being that the American economics of hugely expensive sense-extending diagnostic imaging technologies such as MRI units, CAT scanners, cardiac dynamic stress test machines, etc tended toward the economically problematic. Every medical institution feels compelled to have them to be credible, competitive Players in the market, but everyone also needs to keep them all profitably humming, with viable billable payers at the end of the back office line. And, every additional install exacerbates the billable utilization problem. Damned if you do, damned if you don't...

THE U.S. "HEALTH CARE" "SYSTEM"?

I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes...

See also my more recent take on what I call the "shards" of our fragmented, crazed non-"system."

I frequently say "if you're not confused, you've not been paying attention."

One of the most maddening implications of "An American Sickness" is that the leading GOP "health care reform / repeal ObamaCare" proposals are virtually certain to make things materially worse.

Elisabeth concludes,

EPILOGUE 
The Fate of Empires describes an age of decadence into which all great societies— Rome, Greece, Persia, Great Britain— descend before they finally fall for good. The decadence, according to the author, Sir John Glubb, is due to a period of wealth and power, selfishness, love of money, and loss of a sense of duty. Does this sound familiar? Societies, it says, typically take over two hundred years to get to the age of decadence. American healthcare has arrived far faster. 

The fathers of modern medicine— doctors and scientists like Frederick Banting, who pioneered insulin treatment; Jonas Salk, who discovered the polio vaccine; Albert Starr, who invented a lifesaving artificial heart valve; and Thomas Starzl, who fathered modern organ transplant— helped usher in a new era of scientific healing. They are the reason for medicine’s lofty reputation. But the respect they earned through their noble efforts has been squandered in the past quarter century. The treatments we get and the prices we pay are governed as much by commerce as by humanism or science. The mission of this book is to advocate for a return to a system of affordable, evidence-based, patient-centered care. 

No one player created the mess that is the $ 3 trillion American medical system in 2017. People in every sector of medicine are feeding at the trough: insurers, hospitals, doctors, manufacturers, politicians, regulators, charities, and more. People in sectors that have nothing to do with health— banking, real estate, and tech— have also somehow found a way to extort cash from patients. They all need to change their money-chasing ways. 

To make that happen, however, we patients will need to change our ways too. We must become bolder, more active and thoughtful about what we demand of our healthcare and the people who deliver it. We must be more engaged in finding and pressing the political levers to promote the evolution of the medical care we deserve. 

I hope the book you have just finished has made you not just outraged but also better prepared for these tasks. Now you understand that the free coffee and artwork display in a hospital’s marble atrium aren’t free at all. That what’s sold to you as the newest drug or device to treat your illness may not be, in fact, the best. That the anesthesiologist who comes in to say “hi” before a procedure is perhaps not being kind, but making an appearance so that he and/ or his extender can bill for a consult. You’re wise to the heist and emboldened with new tools and ideas about how to take back your health and our medical system. 

Medicine is still a noble profession. There are many great doctors, nurses, pharmacists, and others working their hearts out, even in these troubled and troubling times. Even as the healthcare sector faces a future of great financial uncertainty and humiliating bureaucracy, many of the best and brightest students are flocking to medical school. They’re doing it because they want to take care of patients, to heal using some of the time-honored tools in the doctor’s black bag as well as the miraculous scientific innovations of the last twenty-five years. That is, after all, the only really compelling reason to go into medicine. 

They want to deliver patient-centered, evidence-based care at a reasonable price. We, the patients, need to help, to rise up and make that possible. We have to remind everyone who has entered our healthcare system in the past quarter century for profit rather than patients that “affordable, patient-centered, evidence-based care” is more than a marketing pitch or a campaign slogan. 

It is our health, the future of our children and our nation. High-priced healthcare is America’s sickness and we are all paying, being robbed. When the medical industry presents us with the false choice of your money or your life, it’s time for us all to take a stand for the latter. [An American Sickness... pp. 328-329]

Between the Introduction and the Epilogue lies a ton of spot-on (albeit frequently aneurism-inducing) detail. It's also the kind of book you can roam around in effectively (which I am still doing; eventually I'll report on her Chapter 18 take on digital health IT).

Chapter by chapter, she recurrently relates her details back to her take on fundamental health care market "rules."

All excellent stuff. Do yourself a favor it you're still on the fence, go to Amazon, read the extensive "Look Inside" preview excepts.

ERRATUM

A comment I recently posted under an article at THCB.

ALL stakeholders in health care, with the exception of patients, argue that they are all “losing money” and need higher prices, or they will pull out of their service domains. Yet somehow “competitive market forces” will make them all happy earning even LESS as we “bring down the cost of health care” for the benefit of patients (who have ZERO individual market leverage, and are ACTUALLY losing money).

CODA

Elisabeth's American Sickness book dedication:

Dedicated to all the patients, doctors, and other healthcare professionals who so generously shared their stories and experiences to bring this book to life. Waiving privacy concerns, they agreed to have their real names appear in print. In the hope of contributing to change in our healthcare system, they spent hours digging up copies of their bills, insurance statements, correspondence, and other documents to provide verification. I’m deeply grateful for their help, commitment, and courage.

They—and all Americans—deserve better, more affordable healthcare.

I will have more to relate shortly on my daughter's worsening circumstance, in the hope that it (like other personal disclosures I have posted over time) will help others.

Speaking of "affordable healthcare," I just did a quick 'n dirty graphic in Illustrator.

What am I missing?
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Much more to come. Meanwhile, buy Elisabeth's book...