"The Price We Pay" by Marty Makary, MD

Above: "The Price We Pay" - Marty Makary, MD - 255 pages.

I completed reading this book today, 17 November 2021.

Insurance companies pass on doctor price gouging, which they reimburse, in the form of increased premiums to everyone else. Everything wrong with health care: People are price gouged for a procedure they don't need after taking medications that were marked up by her pharmacy benefits manager (PBM). "The contrast between the money games of medicine and the mission of our predecessors who worked so hard to earn the public trust couldn't be sharper." One simple thing you can do: ask for a price every tie you are considering a medical service.

This book is about a disturbing regimen of over treating and over charging in the US medical system.

Chapter 1. "Ballooning, stenting, and even lasering harmless plaques in leg arteries has spun completely out of control. It's a cash cow. Many of patients are lured in at community health fairs held by churches. Tests, which should only be given to those having symptoms, given to all attendees.

Chapter 2. Hospital officials inflate bills more and more each year to generate more revenue since their insurance companies pay only part of the sticker prices. Insurers demand bigger and bigger discounts in their contracts with hospitals. Inflated hospital bills are passed along to the public in the form of higher insurance premiums. "Markup-discount game." Remedy: Real price transparency.
..
Chapter 3. Carlsbad Medical Center. Predatory billing practices followed by suing lower income patients and garnishing their wages.

Chapter 4. Makary team seeks to dimension scope of predatory billing accompanied by wage garnishing and suing patients. Team determines practice is extensive, including at non-profit hospitals which enjoy tax advantages. Many hospitals mark up prices 2x to 20x Medicare payout then engage in predatory billing for amount not paid by Medicare. Team identifies rural Nebraska hospital system that makes money with 50% Medicare patients and no predatory billing. Tees up this hospital as a template for others to emulate.

Chapter 5. Rise of for profit ambulance companies which drive out hospital owned service. Lives ruined by $50K ambulance bills. Some third party administrators doing well in keeping costs down. Makary wants state regulation with posting of air ambulance complaints on line.

Chapter 6. Unnecessary C-sections. Use data. Benchmark best practices. Highlight outliers. Apply to C-Section and other surgeries. The power of data. Begin Choose Wisely program at the RWJ Foundation.

Chapter 7. Mohs Surgery abuse. Reimbursements layer by layer. Propensity to excise more layers than really necessary Developing data of outliers. Gaining buy-in from Mohs Surgery community (and obtaining beaucoup cooperation from) for Improving Wisely model.

Chapter 8. Surgeons performing spine surgery when no physical therapy has taken place. Research shows that in most cases physical therapy manages the pain better than the surgery. Data development to identify outliers. Gaining buy-in from spinal surgery doctor community for Improving Wisely model for national exception reporting. Lumpectomy. Tracking number of re-excisions. Tragically, outliers (those performing a higher percentage of re-excisions) were making more money. Gastroenterology doctors (GI) who perform unnecessary hemorrhoid banding. Heart surgeons who replace mitral valve rather than repairing. Repairing is better, but, reimbursements are higher for replacements. Too many surgeons performing outdated practice of surgical repair on one and two year olds for belly button hernia. New learnings show that this "problem" works itself out in most cases by the time a child is six. Surgery is now deemed unnecessary, but, is still performed. End of life: Oncologists recommend measuring the proportion of cancer deaths in an oncologist's practice when the patient is receiving chemotherapy or radiation in the two weeks prior to their death. If 80% to 100% of an oncologist's patients received chemo or radiation within two weeks of dying, the doctor may not be exercising good judgement about when to back off the aggressive treatment in a case that's past hope. In dentistry, silver drop theory treatment for cavity is less expensive and avoids drilling. Drilling, more lucrative, can be overused. Overtreatment penetrates most corners of medicine. Chapter discusses areas where metrics are available to identify outliers. Tees up question of how best to use the data.

Chapter 9. Over prescription of opioids. Must change financial incentives to reward practicing non opioid methods of pain management.

Chapter 10. Overmedication. The risks of medications and procedures are understated because of publication bias and the lack of studies evaluating long-term consequences. One of the leading drivers of health insurance premium increases is the doubling of prescription medications over last decade. Most medications can be avoided with lifestyle changes.

Chapter 11. Changing the system. Discarding "fee for service" and replacing with "patient based care." Emphasis on quality of treatment over quantity. Doctor consultation followed by coach to work action plans with patient. Iora Health, with eight offices, one such operator breaking new ground. Treat for root causes... not for symptoms. Results show better outcomes.

Chapter 12. Price Armageddon when at "out-of-network" hospital , say for emergency. Form: sign to be treated and sign to pay bill. See bill amount after the fact, not before. Solution: Health Care Blue Book ranks hospitals by price fairness. Encourages wise shopping. Legislation to be considered: Require that hospitals report what they are reimbursed by insurance companies as well as overall price.

Chapter 13. Insurance brokers who write contracts based on commissions they receive and not what is best for the insured company. Solution: Charge a consulting fee and take no kick-backs. Brokers not bad people. They are just responding to perverse incentives.

Chapter 14. Pharmacy Benefit Managers (PBMs). PBM's are hired by companies to manage pharmacy benefits for their employees. PBM's routinely gouge their clients by managing "the spread." PBMs bill their clients far in excess what they pay drug companies for pharmaceutical products. Pharmacists gagged from disclosing what they charge PBMs for product. Danny Toth at Timber Ridge Consultants counsels companies to get second opinions from other PBMs. Also, legislation required by state to prohibit PBMs from pricing using the "spread" model.

Chapter 15. Group Purchasing Organizations (GPOs). GPOs serve as middlemen between hospitals and hospital equipment and supply purchases. Front line medical personnel, surgeons, for example, never see new innovations. GPO intervenes and takes kickbacks to promote the product. "Its time we banned all kickbacks in medicine."

Chapter 16. "Today's wellness movement is a $6 billion industry run amok."

Chapter 17. Medical education system is skewed toward things that don't matter. It is focused on rote memorization instead of treating the whole person. No training on pricing failures, overtreatment, or middlemen. Patients lives being ruined by such things as predatory billing practices. Doctors must lead the charge to restore medicine to its mission.

Chapter 18. Insurance companies pass on doctor price gouging, which they reimburse, in the form of increased premiums to everyone else. Everything wrong with health care: People are price gouged for a procedure they don't need after taking medications that were marked up by her pharmacy benefits manager (PBM). "The contrast between the money games of medicine and the mission of our predecessors who worked so hard to earn the public trust couldn't be sharper." One simple thing you can do: ask for a price every tie you are considering a medical service.