Book Review: The Price We Pay by Dr. Marty Makary

By Al Lewis
Aside from the many antediluvian wellness promoters still claiming that our healthcare problems can be solved by browbeating employees into eating more broccoli, there is a legitimate debate between:

(1)   those who argue that the system is corrupt because pricing is out of control vs.
(2)   those who argue the system is corrupt because utilization is out of control

The Price We Pay: What Broke American Health Care and How to Fix It, released September 10th– certain to be a New York Times bestseller like Dr. Marty Makary’s last one (and is probably very close to that point now)—shows quite definitively that the answer is both. (“If overtreatment were a disease, it would rank as one of our leading public health threats.”)


Painstakingly researched with a team of dedicated and highly skilled students and fellows, Dr. Makary traveled around the country collecting first-hand stories at an on-the-ground level rarely seen in health services research.


Dr. Makary has created a niche for himself as a practicing surgeon who also does on-the-ground-research and who also influences health policy. No one else does all three and only few people, like Atul Gawande, do even two of those three. Hence these are not just stories for their own sake, but they feed into the national debate. With the help of this group to raise awareness, they could win the national debate.


One such set of stories, about hospitals suing patients for unpaid bills as a matter of course, has already been featured on NPR, and the hospital in question, Mary Washington in Virginia, has already agreed to cease and desist.


In another city — Carlsbad, New Mexico — it appears that a very significant portion of all the households had been sued by the city’s hospital.  This particular chapter reads like fiction. To parse it in detail would require a spoiler alert. Suffice it to say that after you read it, you will want to sell short the corporation that owns the city’s hospital. Except that the corporation in question – notorious among healthcare industry insiders for having made one of the worst acquisitions in hospital industry history earlier in this decade – is already near bankruptcy. The strategy of suing patients is a last-ditch attempt to prevent it. Not much left to short.


Many hospitals do this, as it turns out, to one degree or another. But it’s not just the hospitals. Turns out there are even worse offenders: ambulances. Air ambulances are the worst of the worst, with one example of a bill for an air ambulance ride that exceed the actual bill from the hospital for a one-week stay.


These companies’ strategies are driven by greed rather than need, it would appear, seeking out patients not with the greatest gaps in care or health disparities but with the greatest ability to pay, which explains why 24 such companies operate in Dallas while none in the under-served Rio Grande Valley.


And that brings us to surprise billing. Yikes! Way worse than I thought…and I thought it was pretty bad.  Fortunately, The Price We Pay recommends some ways to mitigate it.  (I’ve been inspired by this book to create a home-grown solution, which is that the health insurance card carries a “battlefield consent” to treatment in the ER and an agreement to be responsible for reasonable charges not to exceed X times Medicare. ERs have to treat you. You just don’t have to agree to open-ended charges. You don’t want to be negotiating on the spot. A health insurance card like this would create the equivalent of an advance directive for billing.)


Oh, here’s a shocker: Dr. Makary hates “pry, poke and prod” wellness programs. The ‘screening-industrial complex,’ he calls it. Which indeed it is. What, he asks, is so difficult about screening according to USPSTF guidelines, other than costing vendors valuable revenues? Vendor coaching doesn’t come off much better:

A friend invited me to sit in on a company’s wellness class. I can sum up the instructor’s message in three words: “Avoid fatty foods.” There are a few problems with that message. First, it was about the only thing the health “coach” said to the 20 or so bored people in the room. But second, I cringed because it has absolutely no scientific basis. This class risked making people less healthy; it was loaded with misinformation.


The irony is that Dr. Makary works at the same hospital system, Johns Hopkins, as the wellness industry’s prevaricator-in-chief, Ron Goetzel. If Ron can’t convince his own colleagues not to criticize his precious pry, poke and prod programs, it’s unclear why he thinks the rest of us should embrace them. Especially because Mr. Goetzel has already admitted that Dr. Makary – and, for that matter, Johns Hopkins, whose excellent wellness program excludes “pry, poke and prod” – are right in disbelieving him. Pry, poke and prod programs lose money, and all but the best programs are more likely to harm than benefit employees. (In all fairness to Ron, his other employer, IBM, does do pry, poke and prod. That might help explain why it’s been the worst performer in the Dow Jones Index since 2012.)


While many of us disagree on specific solutions to various problems, we can all agree that current “solutions” serve only to benefit entrenched interests.  Legislative remedies are unlikely, as groups defending the status quo have vastly more resources and own vastly more legislators than those trying to disrupt it.


Dr. Marty Makary’s new book The Price We Pay is a chance to get this critical message out directly to the people many industry insiders never meet – the public, the media, and especially the HR and benefits people who heavily rely on information from third-parties like brokers and consultants to make decisions that impact their employees.

Al Lewis is the CEO of Quizzify and is a Senior Advisor to Validation Institute.