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Restoring the Public Trust

In deciding between two high-quality hospitals to deliver her baby, a woman asks for a price. “We can’t give you a price,” she’s told. It turns out that one hospital charges $41,000 and the other $4,000. A working single mom with a $9,000 deductible, she blindly walks into the $41,000 hospital, gets talked into an unnecessary C-section and gets hit for the full cost with a flurry of surprise out-of-network bills. She doesn’t have the money on hand and the bill is sent to collections. She pays in full, but her credit score is damaged, driving up the cost of a mortgage on the house she’s preparing to buy.

Surgeon Marty Makary offers up this mother’s real-life experience as one that encapsulates the major themes of his latest book, The Price We Pay: What Broke American Health Care—and How to Fix It: a lack of transparency, the presence of middlemen and aggressive collection practices that, he argues, are eroding the public trust in the medical profession. 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.”

Makary, chief of islet transplant surgery, holds a joint professorship in health policy and management at the Bloomberg School of Public Health. He serves as executive director of Improving Wisely, a national Robert Wood Johnson Foundation project to lower health care costs by addressing unnecessary medical care. He is also the author of Unaccountable (2013), which was turned into the hit TV series The Resident.

For his new book, Makary visited 22 cities to get a ground-level view of the business of medicine, speaking with doctors, patients, hospital leaders and insurance executives. Among his findings:

  • Vascular surgery centers that prospect for patients at church health fairs, especially in lower-income areas, screening all comers in defiance of scientific consensus guidelines and nudging them toward unnecessary but lucrative follow-up testing and procedures.
  • Hospitals and insurance companies playing an escalating game of markup and discount that’s hidden by nondisclosure agreements and conducted, he says, “by an army of middlemen whose salaries are built into the markup.” Ballooning costs drive up premiums and depress wages.
  • Prices, usually unavailable up front, that vary wildly between institutions without correlation to quality or charity care.

Often, Makary writes, doctors and hospital executives have no idea what their own services cost or how their institution goes after patients to pay. “When one-quarter of patients hesitate to seek care because of price gouging, medical cures are rendered ineffective,” he says. “Cures are no good when people don’t trust us.”

But he also includes powerful bright spots of innovators fixing the problem, including a hospital with upfront pricing, a clinic with a globally capitated annual fee and coordinated care, and doctor-led initiatives to reduce waste. While he has several audiences in mind for his book, Makary appeals to doctors to remember the nobility of their calling, invoking the altruism of Jonas Salk, who, in refusing to patent the polio vaccine, forfeited an estimated $7 billion in today’s money, and the charity of Johns Hopkins, whose founding mission included serving the poor without charge. “These are our patients,” he insists. “We need to call an end to the money games and restore the public trust of our great medical heritage.”

The Price We Pay: What Broke American Health Care—and How to Fix It
Marty Makary, M.D.
Bloomsbury Publishing (2019)