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The Price We Pay: What Broke American Health Care--and How to Fix It

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New York Times bestseller
Business Book of the Year--Association of Business Journalists

From the New York Times bestselling author comes an eye-opening, urgent look at America’s broken health care system--and the people who are saving it--now with a new Afterword by the author.

"A must-read for every American." --Steve Forbes, editor-in-chief, FORBES

One in five Americans now has medical debt in collections and rising health care costs today threaten every small business in America. Dr. Makary, one of the nation’s leading health care experts, travels across America and details why health care has become a bubble. Drawing from on-the-ground stories, his research, and his own experience, The Price We Pay paints a vivid picture of the business of medicine and its elusive money games in need of a serious shake-up. Dr. Makary shows how so much of health care spending goes to things that have nothing to do with health and what you can do about it. Dr. Makary challenges the medical establishment to remember medicine’s noble heritage of caring for people when they are vulnerable.

The Price We Pay offers a road map for everyday Americans and business leaders to get a better deal on their health care, and profiles the disruptors who are innovating medical care. The movement to restore medicine to its mission, Makary argues, is alive and well--a mission that can rebuild the public trust and save our country from the crushing cost of health care.


Editorial Reviews

Review

Dr. Makary takes a deep dive into the real issues driving up the price of health care and explains how we can all take action to restore medicine to its noble mission.” ―Don Berwick MD, senior fellow, Institute for Healthcare Improvement

“[The Price We Pay] is a fascinating look at people and communities throughout America--Dr. Makary blends reportage, research, and personal anecdotes about how money is really spent in healthcare, how we got to where we are today, and who is affected the most. I just started this one, and I already want to tell everyone to read it.” ―BookRiot, "What to Read for #ScienceSeptember"

“A must-read for every American.” ―Steve Forbes, editor-in-chief, FORBES magazine

The Price We Pay is stuffed with examples of predatory billing, confusing costs and statistics that could make you despondent. But there's plenty of honesty, problem-solving and hope to leaven all that despair.” ―Washington Post

“As Democrats turn on the Affordable Care Act in favor of Medicare for all and Republicans seem split on how to fix the American health care system, surgeon and health policy professor Dr. Marty Makary addresses the system's brokenness and offers a hopeful take on how it can be solved in his upcoming book The Price We Pay.” ―The Daily Caller

“Brimming with true accounts that put faces on the numbers, The Price We Pay tours the landscape of contemporary American health care, with a generous sprinkling of hopeful counterexamples, or what the author calls “disruptors.”” ―Hopkins Reader

“Makary's book is a call to action for medical professionals to speak out, businesses to look for better deals, and patients to push back on prices.” ―The Texas Observer

“[A] groundbreaking new treatise on why the cost of going to the doctor in the United States is spiraling out of control at an accelerating pace. . . . [The Price We Pay is] remarkably enlightening on a number of levels as well as exceptionally infuriating on others . . . We are indeed in dire straits, but it is not hopeless. And I think you will agree if you decide to add this one to your reading list. Highly recommended.” ―Bowling Green Daily News

“In this thoroughly reported primer Makary authoritatively and conversationally explains the money games of medicine. . . . He found that working Americans feel that the system is stacked against them; it seems that they're right. . . . Consider this book a powerful call to action for more information about health costs and for restoring the 'noble mission' of treating everyone with fairness and dignity.” ―Booklist, starred review

“I absolutely loved this book. Insightful, sharp, and essential reading--one of the top 5 books I've ever read.” ―Jay Newton-Small, TIME Magazine contributor and author of BROAD INFLUENCE

“Marty Makary is a great storyteller, making accessible the business of medicine and the new ideas disrupting it without losing the important details. Everyone should read this book, and then demand a more transparent and fair system.” ―Shantanu Agrawal MD, President and CEO, the National Quality Forum

“A valuable and illuminating read, full of intriguing insights into the use of decision-making in medicine and health care and how to make things work for all.” ―Cass Sunstein, co-author of NUDGE and Professor, Harvard Law School

Marty Makary is one of the great thought leaders in medicine and his new book, The Price We Pay, brilliantly lifts the veil on the state of modern medicine and the new ideas that are disrupting it.” ―Senator William H. Frist, MD

“Over the course of decades, American health care lost the 'care' component and devolved to a big, wasteful business. In his new book, Marty Makary undertakes an extensive listening tour and astutely deconstructs how this occurred and what we need to do about it.” ―Eric Topol MD, Editor-in-Chief, Medscape; author of THE PATIENT WILL SEE YOU NOW

“Dr. Makary artfully sifts through complex data to shine light on a path for those seeking to build a better health care system.” ―Aneesh Chopra, former Chief Technology Officer of the United States and President of CareJourney

“Marty Makary does a masterful job of describing the business arrangements of health care and their consequences in The Price We Pay. . . . This book is a must-read for people struggling to find new ways to affect health care costs outside of a divisive political situation, in which governmental action on anything is becoming increasingly difficult. Makary reminds us that simple awareness can lead to innovation and change. This reminder is badly needed in an industry that all too often bankrupts its customers.” ―Health Affairs

The Price We Pay vividly portrays inefficiency in the nation's health care system."” ―Minneapolis Star Tribune

“Plain talk from a surgeon and professor who has long studied health care issues and finds the American system badly in need of repair. . . . He clearly demonstrates how medical care is secretive and predatory and why skyrocketing costs can be accounted for by the money games of medicine . . . Makary rightly takes the health care business to task, but he also offers a ray of hope that change can and will happen.” ―Kirkus

“Every once in a while a book comes along that rocks the foundations of an established order that's seriously in need of being shaken. The modern American hospital is that establishment and Unaccountable is that book.” ―Shannon Brownlee, author of Overtreated, on UNACCOUNTABLE

“[Unaccountable] is an eye-opening look at the culture of medicine. And it's not pretty.” ―CNN on UNACCOUNTABLE

“A searing insider's look at what really goes on behind the scenes at major hospitals . . . a galvanizing book full of shocking truths about the current state of health care.” ―Kirkus on UNACCOUNTABLE

“This thought-provoking guide from a leader in the field is a must-read for M.D.s, and an eye-opener for the rest of us.” ―Publishers Weekly on UNACCOUNTABLE

“Marty Makary offers a searing indictment from the inside.” ―Wall Street Journal on UNACCOUNTABLE

About the Author

Dr. Marty Makary is a professor at the Johns Hopkins School of Medicine and Bloomberg School of Public Health and the author of the New York Times bestseller, Unaccountable. He is a leading voice for physicians in The Wall Street Journal, The New York Times, and USA Today, and is Editor-in-Chief of Medpage Today. Marty has published extensively on medical innovation, quality measurement, special issues of vulnerable populations, and health care costs. He served in leadership roles at the W.H.O. and has been elected to the National Academy of Medicine. He leads several national grants on health care transparency and the re-design of health care. Marty is the chief of the Johns Hopkins Center for Islet Transplantation Surgery and is the recipient of the Nobility in Science Award from the National Pancreas Foundation. Previously he served as founding director of the Johns Hopkins Center for Surgical Trials and Outcomes Research. Marty currently serves as chair of the advisory board of African Mission Healthcare. He lives in the Washington, DC area.

 

Customer Review



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Amazing what you can learn from this book!

Dr. Makary is a surgeon and teacher at Johns Hopkins Bloomberg School of Health. I can’t imagine anyone not coming away from this book without a deeper understanding of the health care business and why it costs so much. Here are some of the problems and a few solutions that stood out for me:Price gouging: The story of a woman who had a balloon sinus procedure that is generally ineffective, lasting about 45 minutes in the doctor’s office, who got a bill for $21,000, equivalent to what it costs for open heart surgery at Johns Hopkins. Medicare pays less than $1,000 for a standard joint replacement surgery, “yet one in six U.S. hospitals charge more than $90,000 for it.” One in five Americans currently has medical debt.Uneven billing: Henri, a student from France, was told an operation for his father’s heart attack, would cost $150,000; his father went back to France, where it cost about $15,000. Researchers at the University of Iowa surveyed hospitals, and found that the half who would even answer quoted a range of from $44,000 to $448,000. There was no correlation with quality of care or poverty level. Baby delivery in Boston ranged from $8,000 to $40,000.Surprise billing: “While networks served a purpose, they are now the very reason we have surprise bills.” When investigating a bill for a friend, the billing representative told Makary, “The law allows us to charge whatever we want. If we want to charge a million dollars, she has to pay it”Over treatment/ Unnecessary procedures: Makary and colleagues did a survey of 2100 doctors, who on average believed “21% of everything done in medicine is unnecessary.” He relates that heart stenting was in decline, replaced by better medications. However, vascular procedures were a “cash cow,” and some doctors found a new way to use their skills. They prospected for customers, by working as screeners for peripheral artery disease (measuring blood flow in the legs) at health fairs at churches. (They identified about 1100 churches, synagogues, and mosques that served as vascular screening centers, unaware they were being used.) Leg artery procedures can generate $100,000 in one day when a doctor owns the facility. In the vast majority of cases, there is no evidence to support the procedure. This is perfectly legal.Overmedication: “More than half of Americans are now on four or more medications, according to Consumer Reports.” Makary’s research team found the average person on Medicare is on twelve medications.Middlemen: He describes: “The game creates a giant middle layer of health care; the repricing industry, dedicated to negotiating bills among three or four parties after care is delivered” “One study found that for every ten doctors, the average U.S. hospital has seven nonclinical full-time equivalent (FTE) staff working on billing and insurance functions.”Law suits, garnishing wages, liens on homes: A Carlsbad NM hospital was responsible for about 95% of lawsuits at the courthouse. Because the itemized details of the inflated charges are redacted, and only the total due was listed, the judge had little choice but to find for the hospital. This affects the credit score, thus increasing things like mortgage interest rates. Some hospitals mark up their bills by 2 to 23 times what Medicare would pay, and hospitals playing the markup game were also the most likely to sue. The bills that lead to lawsuits for many hospitals represent less than 1% of their revenue. “Half of metastatic (Stage 4) breast cancer patients in the United States report being pursued by a collection agency.” Downright dirty: “The bill collectors told Meghan there was no need for her to show up in court….She knew that if she didn’t show up, the judge would find for the plaintiff by default.”Charity care: “Throughout the 1960’s, the Internal Revenue Service gave tax-exempt status to non -profit hospitals on the condition that these hospitals provide free or highly discounted care to patients that could not afford it.” In 1969 they changed it to a “community benefit standard,” which creates a debate about what this means. In 2014, the IRS required nonprofit hospitals to indicate who was eligible for free or discounted care, not engage in “extraordinary collection actions” until “reasonable efforts” were made to determine eligibility for financial assistance.Pharmacy benefits: Pharmacy benefit managers (PBMs) who one industry observer said, “collectively manage pharmacy benefits for 266 million Americans, routinely fleece American businesses using clever shell games.” “The Spread” is the difference between what the PBM pays a pharmacy and what they invoice a health plan for. “A PBM can set any copay for patients regardless of the medication or the true cost." This is perfectly legal. “It’s the business model of most of today’s PBMs.” “Secrecy is how everyone in the drug supply chain makes so much money.” “Pharmacies are gagged under their PBM contract to not disclose what they are paid by the PBM.” “Approximately 80% of Americans get their medications through a PBM. PBMs can be integrated with insurance companies, making it hard to switch PBMs. In 2018 “the spreads” of the PBMs being paid by taxpayer money in the state of Ohio was $224 million.Group purchasing organizations: Hospitals usually farm out their purchasing to specialists, GPOs, who may be in another city or state. This gives the hospital purchasing leverage. “Today, GPOs ask manufacturers to pay them pay-to-play fees for product placement in their catalogs.” This is “particularly problematic when GPOs invite a manufacturer to pay a premium fee to become a sole supplier.” “U.S. hospitals that purchase through a GPO went from 68% in 2000 to 98% by 2014.” “In 1987, after intense lobbying by the industry, group purchasers were granted an exception to the anti-kickback law, known as a safe harbor exemption.” “GPO kickbacks inflated health care costs up to $37.5 billion annually.”Ambulance service: Some entrepreneurial folks found a business model of providing air ambulance service separate from the hospital; see also comments under the headings of gouging, surprise bills, and suing. “80% of the more than half a million air ambulance flights a year…are not emergencies but are much more like routine transfers.” “In the 1980’s, there were fewer than 100 air ambulance helicopters nationwide. In 2016, there were 1,045.” (Companies can’t bill Medicaid or Medicare for more than the government pays. but no limit on other people) Cash strapped patients can be seen at the Emergency Room entrances exiting Uber or Lyft vehicles.Lobbying: “Health care stakeholders spent $514 million lobbying Congress in 2016”Wellness programs: From 1990 to 2000, the number of workplace health promotion programs doubled. “Wellness companies often make recommendations that go against task force guidelines.” Genetic or biometric screening sounds good, but can lead to problems, such as data breeches or anxiety around false positives. Sometimes the “screening-industrial complex” uses medical providers as a way to bring in business. “The evidence we do have does not show that these programs are effective.” However, some programs have value—fitness club memberships, yoga classes, medical second opinion services, or accurate nutrition science and lifestyle treatments for illnesses.Some good guys:<<Michael Hansen, Nebraska Hospital Association, promotes healthy living projects in an average socioeconomic community and stays without debt.>>Dr. Rushika Fernandopulle, Iora Health with his “relationship-based” care, with nurses, social workers, nutritionists, and other experts, teaching lifestyle changes with a team approach.>>Jeffrey Rice, who founded Healthcare Bluebook to collect pricing data from partnering employers who self-fund their health care and used data to establish a fair price amount.>>Jose Oliva et al from Florida who passed a law requiring hospitals to show the average amount they are being paid for procedures, rather than the (inflated?) amount they charge.>>David Contorno, who rejected the kickback system of health insurance brokerage to recommend options based only on the best value for employers, in spite of retaliation from his industry.>>Dave Chase who created a process called Health Rosetta to set standards for the health care brokers industry.>>”A new federal law passed in 2018 ended the common practice of prohibiting pharmacists from helping patients find less expensive options.”>>Danny Toth, who does undercover work about pharmacy insurance and helps employers renegotiate contracts to be more fair.Transparency: It is nearly impossible to know in advance what a patient will pay. Insurance discount rates for hospitals vary, and are secret. “There’s good reason for the fog—it’s lucrative.” HOWEVER, one study showed: “Centers that initiated full price transparency saw a 50% increase in patient volume, a 30% increase in revenue, and an increase in patient satisfaction.” “Improving Wisely”: Disturbed by seeing doctors with troubling patterns of deviation from standard practice in areas such as C-section surgery, knee replacements, and trying physical therapy before back surgery, Makary and colleagues gathered data to provide feedback to all doctors who used that procedure, letting them know how they compared with their peers. Doctors liked the feedback, and 85% of the “outliers” changed their ways for the better. There is now a “Practicing Wisely” project that runs metrics in big data for health care organizations to see where their doctors stand in relation to certain benchmarks.

by Jean A. Klein, September 11, 2019


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Useful

There are better books in this vein, but you will pick up some good websites that your physician probably isn't eager for you to know about. And there is one problem: anecdotal is ok, but it tends to be good guys versus bad guys versus woke guys versus the greedy doc running your "urgent care" clinic. We know the system is a disaster, and the author has some good ideas for introducing some market discipline into it--because that's essentially what he's doing. The self-serving tone of the prose apart, the real issue is the notion that somehow the doctors are innocent victims of the system too--who me?--and welcome attempts to reduce their wealth. This from a guy who casually buys a Tesla the way some of us would be a Ford Focus. Sorry, interest groups don't work that way and neither does economics, and throwing in a few words about getting incentives right isn't enough. History suggests that people who milk a system for big rents don't smilingly give them up, no matter what Dr Kildaire here says. So it's going to take something a little deeper if you want to get, no pun intended, a diagnosis. Uwe Reinhardt died before he could finish his remarkable book "Priced Out." Go there for some answers, and some of the data that this gentleman claims he is in possession of.

by El Viejo Topo, October 27, 2019


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Healthcare is now the largest employer in the US economy

Everyone needs an understanding of what is driving healthcare quality and costs. The two are inextricably linked. As a physician I was trained that it was unethical to consider cost when making treatment recommendations. Not to mention the fact that it was almost impossible for me to ever get access to that information. I think that now that it is unethical not to consider cost as 1/5 Americans is now in collection proceedings for medical bills and 1/2 of bankruptcies involve medical bills. If you are a physician you should read this and then look for value based business models that will align your interests with the patients. If you are a patient, and we all are or will be, you should read this to know what is driving these costs before it is too late. If you are an employer you should read this before your health plan is up for renewal. If you are a politician, you should read as an overview of where many of the skeletons are buried in this Healthcare crisis. Finally, if you are on the board of or an administrator for a hospital or health system, please read this and look for ways to align incentives between your organization and your patients. Medical care accounts for less than 20% of health. Social determinants are much more responsible for overall well-being. Forcing people to lose their homes will not improve health no matter how high tech your interventions are.

by Dr. Dan, September 21, 2019


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Perspective from Outside the USA - from the UK and Australia

This book is an absolute must read for anyone involved in health care provision, world wide. The American approach to health care has universally been viewed as obscene, as how can health care provision be a for-profit business?The red necked right wing in the USA carp on endlessly about the horrors of "socialist medicine" - which is actually the provision of health care to those who need it, rather those who can afford it.I think there are a few fundamentals that should define a country as "First World" - education for all, health for all, real freedom to go about your daily life without fear, and provision for our societies elders who have given the country so much for so long. America provides none of these - education is expensive, health care is for profit, complete lack of gun control now has schoolkids doing "active shooter" sims in class rooms, and the elderly who are not wealthy just die out.The USA is third world in everything except except armed power.God help us all!

by Amazon Customer, June 6, 2020


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A must read...

Must read for anyone looking to understand the US healthcare system. A shocking, infuriating, but ultimately hopeful look at how free market forces can bring positive change to an industry ripe with grey-area corruption and greed

by John Collins, April 28, 2020



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