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The Price We Pay: What Broke American Health Care--and How to Fix It
"A must-read for every American and business leader." --Steve Forbes, editor-in-chief, FORBES
From the New York Times bestselling author of Unaccountable comes an eye-opening, urgent look at America's broken health care system--and the people who are saving it.
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 price-gouging, middlemen, and a series of 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 roadmap 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.
From the New York Times bestselling author of Unaccountable comes an eye-opening, urgent look at America's broken health care system--and the people who are saving it.
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 price-gouging, middlemen, and a series of 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 roadmap 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.
288 pages, Kindle Edition
First published January 1, 2019
1233 people are currently reading
9408 people want to read
About the author
Marty Makary
12 books210 followersDr. Makary is a surgeon and researcher at Johns Hopkins University School of Medicine. He is the author of Unaccountable by Bloomsbury Press and a national advocate for transparency in health care.
Dr. Makary was the lead author of the original publications on the surgery checklist which he and Dr. Pronovost adapted from their experience with patient safety in the ICU. He subsequently served in leadership roles at the United Nations W.H.O., where the surgery checklist was adopted and expanded to become the W.H.O. surgery checklist. Dr. Makary also led the W.H.O. technical workgroup on developing metrics to measure surgical quality worldwide.
Dr. Makary’s current efforts focus on patient empowerment through increased transparency of medical information. He speaks nationally on the future of health care, accountability in medicine,
and new innovations to streamline health systems. He is the author of over 150 publications and a leading textbook of surgery, in addition to the New York Times Best Selling Book, "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care." Dr. Makary is the recipient of grants from the Department of Health & Human Services to study surgical outcomes and is currently funded by AHRQ to implement an intervention to decrease surgical complications in 100 American College of Surgeons participating hospitals. He serves on the leadership council of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and is a frequent medical commentator for CNN and Fox News.
Clinically, he practices laparoscopic surgical oncology and is the director of the Johns Hopkins Pancreas Islet Transplantation Center. He lives in the Washington D.C. area.
Dr. Makary was the lead author of the original publications on the surgery checklist which he and Dr. Pronovost adapted from their experience with patient safety in the ICU. He subsequently served in leadership roles at the United Nations W.H.O., where the surgery checklist was adopted and expanded to become the W.H.O. surgery checklist. Dr. Makary also led the W.H.O. technical workgroup on developing metrics to measure surgical quality worldwide.
Dr. Makary’s current efforts focus on patient empowerment through increased transparency of medical information. He speaks nationally on the future of health care, accountability in medicine,
and new innovations to streamline health systems. He is the author of over 150 publications and a leading textbook of surgery, in addition to the New York Times Best Selling Book, "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care." Dr. Makary is the recipient of grants from the Department of Health & Human Services to study surgical outcomes and is currently funded by AHRQ to implement an intervention to decrease surgical complications in 100 American College of Surgeons participating hospitals. He serves on the leadership council of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and is a frequent medical commentator for CNN and Fox News.
Clinically, he practices laparoscopic surgical oncology and is the director of the Johns Hopkins Pancreas Islet Transplantation Center. He lives in the Washington D.C. area.
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December 22, 2023
This book is a bit frustrating because the author is appropriately outraged about some of the flaws in the U.S. health system, yet refuses to think about the primary underlying cause of them and never brings it up. So the solutions he arrives at, while positive (and some of which he has caused to be implemented), are inadequate.
The flaws he sees are overcharging and overbilling of everything medical; lack of transparency in pricing; hospitals suing patients who can’t pay; delivery of unnecessary care to increase revenues; and layers of middlemen in hospital, pharma, and insurance groups that squeeze extra profit out for themselves. He sees greed and profit seeking everywhere, rightly. But he never questions the reason for this: our health system is market-based, therefore it is profit-driven. He never wonders if universal healthcare could address this problem, if making the federal government the sole buyer of healthcare products and services could reform the system. His solutions remain tinkering around the edges.
He believes that transparency in pricing will encourage competition and drive prices down. Facilities will post prices on their websites (both what is charged, and what is billed). Of course transparency in pricing is desirable. But patients can’t just go anywhere, attracted by the lowest price – they need to stay in their network, which their insurance determines. Most people can’t pick and choose from among 15 hospitals within a certain radius, because only some of those hospitals and doctors will be in-network for them. And if you go out of network your out of pocket costs might be unlimited.
Makary did push pricing transparency to become law; hospitals and facilities are now supposed to post charges on their websites, but some make it hard to find. In fact the Affordable Care Act already required them to do this, but the rule wasn’t followed or enforced.
Makary, a pancreatic surgeon at Johns Hopkins, is a good storyteller and some of his stories will curl your hair. Adam, a Frenchman visiting his son in D.C., went to an ER with chest pains. He was stabilized and the next day doctors recommended a heart bypass operation. It would cost $150,000, a rep said. Adam called friends in France who said that the same operation there would cost $15,000. When he told the hospital rep he would return to France to get the surgery for the cost savings, they dropped the price to $50,000. “Alarmed at the sudden discount, Adam politely declined the offer.” As he left the hospital, the rep chased after him, offering to do it for $25,000.
The president of a large insurance company admitted, “Insurers fight for a bigger discount every time they renew a contract with a hospital. Then hospitals go around and inflate their prices. It’s a game.” The secret discount that an insurance company gets (so that insured patients will get a better rate than uninsured patients) ranges from 4% to 90%, Makary found.
“Hospitals, in order to ensure they have enough cash on hand on a macro level, spend a lot of energy playing the markup and discount game….if a hospital made $100 million the prior year, dialing up all bills by 5% as their expenses go up by 4% is a safe bet without having to accurately itemize every service. Hospitals use software called the ‘chargemaster’ that automatically inflates prices to achieve a desired margin.” Hospitals defend the automatic markups by claiming they’re to compensate for charity care and the uninsured, and they claim no one really pays those prices. Both are false; Makary even finds a group who pays the full hospital prices: the Amish, who “believe in paying their bills in full” and pool resources from the entire community, coming to the hospital with bags of cash.
One big driver of costs is the repricing industry, “dedicated to negotiating bills among three or four parties after care is delivered.” In a typical hospital, for every ten doctors, there are seven nonclinical staff working solely on billing and insurance processing. All of this extra lard helps explain why the U.S. spends twice as much per person on healthcare as other wealthy nations.
Makary travels to Carlsbad, New Mexico, where many residents had been sued by the Carlsbad Medical Center – and were having their paychecks garnished – for outrageous amounts of medical debt. Everyone he ran into on his visit, including the receptionist at his hotel, was being sued. He went to the courthouse to observe the lawsuits. “Carlsbad Medical Center is 95% of the lawsuits here at the courthouse,” the clerk told him. There were thousands of garnishment cases, and the hospital had won nearly all of them. Finally he talks to one of the judges. Was it true that 95% of the cases were the hospital going after patients? Yes, she says. She was a criminal judge, not civil, but “the lawsuits from the hospital are a burden on our limited administrative capacity.” In fact, the judge and her husband had both been sued by Carlsbad Medical Center.
In Virginia, Makary found that nonprofit hospitals were more likely to sue patients than the few for-profit hospitals. Mary Washington Hospital and UVA were the worst offenders. Nonprofit hospitals pay no taxes – federal, state, or local – because the IRS credits them with “community benefit spending” which may include free or discounted care. But the nonprofit designation doesn’t mean these hospitals are charging less than for-profit hospitals. They’re marking up their bills by 2-23 times what Medicare pays for the same services. And because of a change in the wording of the IRS regulation, they don’t even have to offer free or discounted care anymore.
There’s a chapter about the enormous bills generated by air ambulance services – the helicopter that picks you up from your car crash is most likely out of network and the cost to the patient could be tens of thousands or hundreds of thousands.
Makary eagerly talks up his market-oriented, band-aid solutions to the bloat. One is the website SesameCare.com, where he is Chief Medical Officer. This is a site where doctors can post cash prices for their services, insurance not accepted. The site explains, “Sesame’s mission is to eliminate the pain of your high health insurance deductible (or not having health insurance at all) by building a first-of-its-kind, super simple healthcare system. The Sesame Marketplace makes half-priced, high-quality health care accessible to hundreds of millions of Americans: No surprise fees or bills. No waiting to see a doctor. And no insurance needed.” “Doctor appointments as low as $29, book in minutes,” says the site. You can select a service (I looked at breast reduction, DEXA scan, arthroscopic rotator cuff repair, basic metabolic panel, IUD device, hammertoe repair, and cardiology visit new patient). I input, for geographic variety, Dallas, Sarasota, Phoenix, Charleston, and Annapolis. But none of these services were available in any of these places. “Hammertoe repair will be available soon in Dallas, TX,” it told me. “Basic metabolic panel will be available soon in Annapolis, MD.” Only when I clicked “One Time Visit” did some doctors pop up, and they were only available for telehealth appointments, and were only primary care doctors. Yes, this IS how you keep prices low: you only offer primary care, and only telehealth visits! Also, I found out that the $29 appointment was only available for people who joined Sesame Plus, which costs $11/month or $99/year. The other executives at SesameCare have worked at McKinsey, Universal Studios, Goldman Sachs, GasBuddy, Drizly (an alcohol delivery service!), Vimeo, AOL, Ebay, PayPal, Microsoft, and Equinox. Jesus wept.
Makary is also the Chief Medical Advisor at VezaHealth, a “medical second opinion service” with only one other principal listed, its founder. The website promises “remote second opinions,” “nurse navigation” (“Our Registered Nurses deliver white-glove high-touch nursing services to all program participants, even those who do not need/want a Remote Second Opinion”), and “legal assistance,” but nothing was clickable. Whatever VezaHealth is offering, you can’t get it from the website.
I’m sure he gets some nice consulting fees and compensation from all of these start-ups. Promising to get rid of bloat can be very profitable.
Chapter 12 contains important advice about what to do when you go the Emergency Room. By law, ERs must treat you when you show up, regardless of your ability to pay, insurance status, or whether the facility is in or out of network for you. Still, you have to be careful. Makary was there with a friend, Dina, and guided her through the process. They will bring a form for you to sign, which is two separate contracts: one says that you agree to be treated. The other says that you agree to pay 100% of whatever is charged. You should sign the first one but not the second one. Read it through and cross out the clause that requires you to pay 100%. Then sign. In this situation, the staff brought an iPad and asked her to sign the iPad; Makary insisted they print out the form instead. Then Dina was able to cross out the clause and sign.
Soon Dina had $60,000 worth of bills, the out-of-network rate. Makary helped her get an itemized bill (which cost $25). He used a website that analyzes pricing data (HealthcareBluebook.com, which is available to employers but not for retail or patient use) to find out that for an in-network patient, the hospital would have been paid $12,000 by insurance for the same procedure, a 500% markup. Makary asked if the hospital would accept $12k. They got upset and told him the law allowed them to charge out-of-network patients whatever they wanted. He asked to speak to the director of revenue cycle; they said no. He spoke to a supervisor and explained he was a doctor. A week later the director called him. Makary explained that Dina had crossed out the clause agreeing to pay 100%. So she had no contractual obligation to pay. The director offered financial aid (which hospitals are already required to do under the ACA). He offered a 10% discount and a monthly payment plan. Makary said that Dina was willing to pay $12,000. The director said he could reduce the bill to $30,000. Makary asked what an in-network insurance company would have paid for Dina’s bill. The director said he wasn’t allowed to disclose his discounted rate with any insurance company. They continued to haggle, with Makary offering $12,000 and the director dropping to $25k, $20k, and $19k. Dina’s bill got sent to collections; Dina demanded that collections send her a written record of her obligation to pay the bill, which didn’t exist since she had crossed it out. Collections stopped calling her. Although Dina had no legal obligation to pay, she made a $5,000 charitable donation to the hospital, and paid the surgeon’s portion of the bill.
Makary spends some time praising Healthcare Bluebook because it helps patients spend less by increasing transparency. He calls it a “disruptor,” just as the other for-profit companies like SesameCare and VezaHealth are. Hang on to your wallet when you hear this Silicon Valley term, because these companies are all barnacles on the giant healthcare-industrial complex ship. If we had universal healthcare we wouldn’t need all these “disruptor” startups, we wouldn’t need a for-profit company to sell our employers transparent pricing data, because the government would mandate that all pricing be transparent for everyone, and this data would be free of charge.
There’s a reason this was named “Business Book of the Year” by the Association of Business Journalists: it’s very pro-business.
The weirdest part of the book is where Makary spends a paragraph discussing “faith-based sharing ministries.” These are groups whose members pool resources to help each other out with medical bills. He writes, “The plans are typically less expensive than insurance. But don’t rely on your health insurance broker to tell you about this low-cost option. Samaritan Ministries and other health insurance co-ops don’t pay kickbacks to brokers.” My mouth fell open when I read this. The idea that a surgeon at a major hospital would be advocating for these plans is ludicrous and horrifying. These “plans” are less expensive than insurance because they have none of the guarantees of insurance. Health insurance, no matter how much we may dislike it, is highly regulated, both at the state and federal level. These plans are not, because they’re religious. (No regulation of religion.) If you join one of these plans you have no guarantee that your bills will be paid, because there are no contracts, only trust among members.
The flaws he sees are overcharging and overbilling of everything medical; lack of transparency in pricing; hospitals suing patients who can’t pay; delivery of unnecessary care to increase revenues; and layers of middlemen in hospital, pharma, and insurance groups that squeeze extra profit out for themselves. He sees greed and profit seeking everywhere, rightly. But he never questions the reason for this: our health system is market-based, therefore it is profit-driven. He never wonders if universal healthcare could address this problem, if making the federal government the sole buyer of healthcare products and services could reform the system. His solutions remain tinkering around the edges.
He believes that transparency in pricing will encourage competition and drive prices down. Facilities will post prices on their websites (both what is charged, and what is billed). Of course transparency in pricing is desirable. But patients can’t just go anywhere, attracted by the lowest price – they need to stay in their network, which their insurance determines. Most people can’t pick and choose from among 15 hospitals within a certain radius, because only some of those hospitals and doctors will be in-network for them. And if you go out of network your out of pocket costs might be unlimited.
Makary did push pricing transparency to become law; hospitals and facilities are now supposed to post charges on their websites, but some make it hard to find. In fact the Affordable Care Act already required them to do this, but the rule wasn’t followed or enforced.
Makary, a pancreatic surgeon at Johns Hopkins, is a good storyteller and some of his stories will curl your hair. Adam, a Frenchman visiting his son in D.C., went to an ER with chest pains. He was stabilized and the next day doctors recommended a heart bypass operation. It would cost $150,000, a rep said. Adam called friends in France who said that the same operation there would cost $15,000. When he told the hospital rep he would return to France to get the surgery for the cost savings, they dropped the price to $50,000. “Alarmed at the sudden discount, Adam politely declined the offer.” As he left the hospital, the rep chased after him, offering to do it for $25,000.
The president of a large insurance company admitted, “Insurers fight for a bigger discount every time they renew a contract with a hospital. Then hospitals go around and inflate their prices. It’s a game.” The secret discount that an insurance company gets (so that insured patients will get a better rate than uninsured patients) ranges from 4% to 90%, Makary found.
“Hospitals, in order to ensure they have enough cash on hand on a macro level, spend a lot of energy playing the markup and discount game….if a hospital made $100 million the prior year, dialing up all bills by 5% as their expenses go up by 4% is a safe bet without having to accurately itemize every service. Hospitals use software called the ‘chargemaster’ that automatically inflates prices to achieve a desired margin.” Hospitals defend the automatic markups by claiming they’re to compensate for charity care and the uninsured, and they claim no one really pays those prices. Both are false; Makary even finds a group who pays the full hospital prices: the Amish, who “believe in paying their bills in full” and pool resources from the entire community, coming to the hospital with bags of cash.
One big driver of costs is the repricing industry, “dedicated to negotiating bills among three or four parties after care is delivered.” In a typical hospital, for every ten doctors, there are seven nonclinical staff working solely on billing and insurance processing. All of this extra lard helps explain why the U.S. spends twice as much per person on healthcare as other wealthy nations.
Makary travels to Carlsbad, New Mexico, where many residents had been sued by the Carlsbad Medical Center – and were having their paychecks garnished – for outrageous amounts of medical debt. Everyone he ran into on his visit, including the receptionist at his hotel, was being sued. He went to the courthouse to observe the lawsuits. “Carlsbad Medical Center is 95% of the lawsuits here at the courthouse,” the clerk told him. There were thousands of garnishment cases, and the hospital had won nearly all of them. Finally he talks to one of the judges. Was it true that 95% of the cases were the hospital going after patients? Yes, she says. She was a criminal judge, not civil, but “the lawsuits from the hospital are a burden on our limited administrative capacity.” In fact, the judge and her husband had both been sued by Carlsbad Medical Center.
In Virginia, Makary found that nonprofit hospitals were more likely to sue patients than the few for-profit hospitals. Mary Washington Hospital and UVA were the worst offenders. Nonprofit hospitals pay no taxes – federal, state, or local – because the IRS credits them with “community benefit spending” which may include free or discounted care. But the nonprofit designation doesn’t mean these hospitals are charging less than for-profit hospitals. They’re marking up their bills by 2-23 times what Medicare pays for the same services. And because of a change in the wording of the IRS regulation, they don’t even have to offer free or discounted care anymore.
There’s a chapter about the enormous bills generated by air ambulance services – the helicopter that picks you up from your car crash is most likely out of network and the cost to the patient could be tens of thousands or hundreds of thousands.
Makary eagerly talks up his market-oriented, band-aid solutions to the bloat. One is the website SesameCare.com, where he is Chief Medical Officer. This is a site where doctors can post cash prices for their services, insurance not accepted. The site explains, “Sesame’s mission is to eliminate the pain of your high health insurance deductible (or not having health insurance at all) by building a first-of-its-kind, super simple healthcare system. The Sesame Marketplace makes half-priced, high-quality health care accessible to hundreds of millions of Americans: No surprise fees or bills. No waiting to see a doctor. And no insurance needed.” “Doctor appointments as low as $29, book in minutes,” says the site. You can select a service (I looked at breast reduction, DEXA scan, arthroscopic rotator cuff repair, basic metabolic panel, IUD device, hammertoe repair, and cardiology visit new patient). I input, for geographic variety, Dallas, Sarasota, Phoenix, Charleston, and Annapolis. But none of these services were available in any of these places. “Hammertoe repair will be available soon in Dallas, TX,” it told me. “Basic metabolic panel will be available soon in Annapolis, MD.” Only when I clicked “One Time Visit” did some doctors pop up, and they were only available for telehealth appointments, and were only primary care doctors. Yes, this IS how you keep prices low: you only offer primary care, and only telehealth visits! Also, I found out that the $29 appointment was only available for people who joined Sesame Plus, which costs $11/month or $99/year. The other executives at SesameCare have worked at McKinsey, Universal Studios, Goldman Sachs, GasBuddy, Drizly (an alcohol delivery service!), Vimeo, AOL, Ebay, PayPal, Microsoft, and Equinox. Jesus wept.
Makary is also the Chief Medical Advisor at VezaHealth, a “medical second opinion service” with only one other principal listed, its founder. The website promises “remote second opinions,” “nurse navigation” (“Our Registered Nurses deliver white-glove high-touch nursing services to all program participants, even those who do not need/want a Remote Second Opinion”), and “legal assistance,” but nothing was clickable. Whatever VezaHealth is offering, you can’t get it from the website.
I’m sure he gets some nice consulting fees and compensation from all of these start-ups. Promising to get rid of bloat can be very profitable.
Chapter 12 contains important advice about what to do when you go the Emergency Room. By law, ERs must treat you when you show up, regardless of your ability to pay, insurance status, or whether the facility is in or out of network for you. Still, you have to be careful. Makary was there with a friend, Dina, and guided her through the process. They will bring a form for you to sign, which is two separate contracts: one says that you agree to be treated. The other says that you agree to pay 100% of whatever is charged. You should sign the first one but not the second one. Read it through and cross out the clause that requires you to pay 100%. Then sign. In this situation, the staff brought an iPad and asked her to sign the iPad; Makary insisted they print out the form instead. Then Dina was able to cross out the clause and sign.
Soon Dina had $60,000 worth of bills, the out-of-network rate. Makary helped her get an itemized bill (which cost $25). He used a website that analyzes pricing data (HealthcareBluebook.com, which is available to employers but not for retail or patient use) to find out that for an in-network patient, the hospital would have been paid $12,000 by insurance for the same procedure, a 500% markup. Makary asked if the hospital would accept $12k. They got upset and told him the law allowed them to charge out-of-network patients whatever they wanted. He asked to speak to the director of revenue cycle; they said no. He spoke to a supervisor and explained he was a doctor. A week later the director called him. Makary explained that Dina had crossed out the clause agreeing to pay 100%. So she had no contractual obligation to pay. The director offered financial aid (which hospitals are already required to do under the ACA). He offered a 10% discount and a monthly payment plan. Makary said that Dina was willing to pay $12,000. The director said he could reduce the bill to $30,000. Makary asked what an in-network insurance company would have paid for Dina’s bill. The director said he wasn’t allowed to disclose his discounted rate with any insurance company. They continued to haggle, with Makary offering $12,000 and the director dropping to $25k, $20k, and $19k. Dina’s bill got sent to collections; Dina demanded that collections send her a written record of her obligation to pay the bill, which didn’t exist since she had crossed it out. Collections stopped calling her. Although Dina had no legal obligation to pay, she made a $5,000 charitable donation to the hospital, and paid the surgeon’s portion of the bill.
Makary spends some time praising Healthcare Bluebook because it helps patients spend less by increasing transparency. He calls it a “disruptor,” just as the other for-profit companies like SesameCare and VezaHealth are. Hang on to your wallet when you hear this Silicon Valley term, because these companies are all barnacles on the giant healthcare-industrial complex ship. If we had universal healthcare we wouldn’t need all these “disruptor” startups, we wouldn’t need a for-profit company to sell our employers transparent pricing data, because the government would mandate that all pricing be transparent for everyone, and this data would be free of charge.
There’s a reason this was named “Business Book of the Year” by the Association of Business Journalists: it’s very pro-business.
The weirdest part of the book is where Makary spends a paragraph discussing “faith-based sharing ministries.” These are groups whose members pool resources to help each other out with medical bills. He writes, “The plans are typically less expensive than insurance. But don’t rely on your health insurance broker to tell you about this low-cost option. Samaritan Ministries and other health insurance co-ops don’t pay kickbacks to brokers.” My mouth fell open when I read this. The idea that a surgeon at a major hospital would be advocating for these plans is ludicrous and horrifying. These “plans” are less expensive than insurance because they have none of the guarantees of insurance. Health insurance, no matter how much we may dislike it, is highly regulated, both at the state and federal level. These plans are not, because they’re religious. (No regulation of religion.) If you join one of these plans you have no guarantee that your bills will be paid, because there are no contracts, only trust among members.
November 18, 2019
In The Price We Pay, Marty Makary, an accomplished surgeon at what is considered to be one of the founding institutions of modern American medicine, bears witness to the clusterfuck that is American health care practice.
Bearing witness is the psychological practice of acknowledging that something exists or is true and the corresponding act of sharing ones individual experience about that truth. In his non-partisan (thank God) deconstruction of the abysmal American system, which neither functions on a free market nor in accordance with adequate policy safeguards, Marty graciously acknowledges time and again that he himself was ignorant of the realities of the broken system, despite operating within the belly of the beast. It's his entrenched position and professional credibility, however, that allow him to network thoroughly and gather such critical insight into the system as a whole. What is more, it's his strength of character, coupled with his commitment to the Hippocratic Oath, that motivate him to report back to the general public so as to motivate change, and thereby prevent further financial, emotional, and physical harm which are the current dividends of a system focused on inappropriate care.
The book is told in three parts. The following are descriptions and summaries of the contents:
Part 1 - Gold Rush (Bad actors operate legally within the system with impunity.)
1. Predatory health screenings which commonly target elderly, high-risk, and rural populations encourage unnecessary medical treatment. They are short on actual information and long on financial incentives to recruit new customers.
2. Makary summarizes the bad economics of American health care, to wit: price-gouging, insurance networks as analogous to protection rackets, lack of price transparency, and the creation of a repricing industry.
3. Inquiry into Carlsbad Medical Center and it's medical billing as akin to predatory lending. The hospital charges unreasonable prices, and then uses civil court to strong-arm patients into paying by way of garnished wages and ruined credit.
4. Further inquiry into predatory billing in other hospitals. Makary learns that non-profits are as culpable as for-profits at predatory billing, despite their tax exempt status. “The interest and court fees amounted to 60% of the principal. That sounds less like a hospital that’s there to serve and more like a payday lender that’s trying to hound a patient in debt. Those aren’t quite loan shark interest rates, but if you’re asking ‘What would Jesus do?’, I’m pretty sure this ain’t it.”
5. Makary analyzes the air ambulance industry to show how runaway costs function within one sector of health care.
Part 2 - Improving Wisely (Pattern analysis and fostering competitiveness between surgeons can improve treatment outcomes.)
6. Makary discusses how the philosophical underpinnings of traditional health care quality assessments must be reconsidered. In our current assessment of "appropriate care", we consider complication rates, re-hospitalization rates, process reports, etc., but we don't focus on whether the procedure was appropriate in the first place or lifestyle factors for the patient in the first place. Makary proposes a new metric called "Improving Wisely".
7. A case study of "Improving Wisely" as it pertains to Mohs surgery. Peer bench-marking and realignment of incentives resulted in millions of direct savings to Medicare.
8. Makary applies the underpinnings of the previous two chapters to other types of care such as breast surgery, cardiac surgery, gastroenterology, etc.
9. Interpreting the opioid crisis by understanding the application of practice patterns.
10. Makary argues that over-treatment is as bad, if not worse, than under-treatment. The opioid crisis, antibiotic resistance, increasing health care costs, thyroid cancer surgeries, and other issues all result from over-treatment. “For years, health care reform in Washington D.C., has asked one question: How do we pay for health care? But the real question is: How do we fix the health care system? Addressing the epidemic of too much medical care (which doctors believe represents 21% of all medical care delivered) is a practical solution. My own medical experiences have reminded me that the problem is not just administrative waste, it’s clinical waste as well that’s driving up the health care costs for everyone.”
Part 3 - Redesigning Health Care (Makary analyzes less well-known reasons why health care costs are increasing, from Pharmacy Benefit Managers to quasi-ethical Wellness Programs at work.)
11. The author introduces several companies who are focused on re-designing health care using a relationship-based model of care: Iora Health, ChenMed, and Oak Street Health.
12. Price transparency is a necessary prerequisite to any health care reform, particularly considering price transparency yields quality transparency.
13. Health care brokerage (an industry notorious for trade secrets, predatory retention, and misaligned sales incentives) is a flaw analogous the the brokerage of CDOs which resulted in the financial crisis of 2007. Makary proposes self-insuring as well as finding "Rosetta certified" brokers as a solution.
14. Many people don't know that Pharmacy Benefit Managers exists, and they exist as yet another racket within health care. The goal of a PBM is to increase the spread, or the difference in amount between what they pay a pharmacy and what they invoice a health plan for medication. The PBM keeps any rebates the drug manufacturers or pharmacists offer, and many times the PBMs are owned by the health insurance company they work for (thus increasing the profit margin). “The PBMs have gone to great lengths to keep real prices secret, using a fog of fees, rebates, and discounts that make a true value too complicated for anyone to determine. Even if an employer figured out the spread on a few medications, there are thousands of these meds and they go by different names, have different comparables, different generics, different schedules, and different dosages - and each combination of these variables is priced differently.”
15. Makary summarizes the chapter himself: “The conflicts of interest inherent in the modern GPO (Group Purchasing Organization) business model continue to limit innovation, drive up prices, and cause unacceptable shortages for the most basic drugs and medical supplies.” Group Purchasing Organizations are the middlemen who purchase hospital supplies, and those GPOs may not even be in the same state as the hospital for whom they are acting.
16. Wellness committees are invasive, quasi-ethical, and have no scientific credibility with respect to commonplace health metrics. The employment of wellness committees nationwide can be attributed to pseudoscience, governmental support, and the illusion of employee benefits.
17. Medical schools should evolve to teach more holistic and care-centered medicine as opposed to rote memorization. Our public discourse about health care should match the perceived realities instead of distancing us from the issue.
Like any expose on American health care, Makary's book is frustrating. It's frustrating because powerful forces have designed an unwinnable game that Americans are obligated to play. He concludes his book with a call to action, both for those within the medical field and without, though he has a special call for those within medicine considering they are to do no harm, therefore it is their ethical responsibility to change the system. Though the system is broken, Makary does a good job including reasons to be optimistic in every chapter. He regularly cites specific doctors and clinics that are doing their best to provide quality care focused on a different, more appropriate understanding of what "care" means. I had no issue with Makary's quality of writing, and the book moved quickly and was full of excellent passages to note. The lack of politics within this book cannot be understated or over-appreciated.
I'll borrow from The Wire and conclude with the following: "We used to heal people in this country. Now we just put our hand in the next guy's pocket."
Bearing witness is the psychological practice of acknowledging that something exists or is true and the corresponding act of sharing ones individual experience about that truth. In his non-partisan (thank God) deconstruction of the abysmal American system, which neither functions on a free market nor in accordance with adequate policy safeguards, Marty graciously acknowledges time and again that he himself was ignorant of the realities of the broken system, despite operating within the belly of the beast. It's his entrenched position and professional credibility, however, that allow him to network thoroughly and gather such critical insight into the system as a whole. What is more, it's his strength of character, coupled with his commitment to the Hippocratic Oath, that motivate him to report back to the general public so as to motivate change, and thereby prevent further financial, emotional, and physical harm which are the current dividends of a system focused on inappropriate care.
The book is told in three parts. The following are descriptions and summaries of the contents:
Part 1 - Gold Rush (Bad actors operate legally within the system with impunity.)
1. Predatory health screenings which commonly target elderly, high-risk, and rural populations encourage unnecessary medical treatment. They are short on actual information and long on financial incentives to recruit new customers.
2. Makary summarizes the bad economics of American health care, to wit: price-gouging, insurance networks as analogous to protection rackets, lack of price transparency, and the creation of a repricing industry.
3. Inquiry into Carlsbad Medical Center and it's medical billing as akin to predatory lending. The hospital charges unreasonable prices, and then uses civil court to strong-arm patients into paying by way of garnished wages and ruined credit.
4. Further inquiry into predatory billing in other hospitals. Makary learns that non-profits are as culpable as for-profits at predatory billing, despite their tax exempt status. “The interest and court fees amounted to 60% of the principal. That sounds less like a hospital that’s there to serve and more like a payday lender that’s trying to hound a patient in debt. Those aren’t quite loan shark interest rates, but if you’re asking ‘What would Jesus do?’, I’m pretty sure this ain’t it.”
5. Makary analyzes the air ambulance industry to show how runaway costs function within one sector of health care.
Part 2 - Improving Wisely (Pattern analysis and fostering competitiveness between surgeons can improve treatment outcomes.)
6. Makary discusses how the philosophical underpinnings of traditional health care quality assessments must be reconsidered. In our current assessment of "appropriate care", we consider complication rates, re-hospitalization rates, process reports, etc., but we don't focus on whether the procedure was appropriate in the first place or lifestyle factors for the patient in the first place. Makary proposes a new metric called "Improving Wisely".
7. A case study of "Improving Wisely" as it pertains to Mohs surgery. Peer bench-marking and realignment of incentives resulted in millions of direct savings to Medicare.
8. Makary applies the underpinnings of the previous two chapters to other types of care such as breast surgery, cardiac surgery, gastroenterology, etc.
9. Interpreting the opioid crisis by understanding the application of practice patterns.
10. Makary argues that over-treatment is as bad, if not worse, than under-treatment. The opioid crisis, antibiotic resistance, increasing health care costs, thyroid cancer surgeries, and other issues all result from over-treatment. “For years, health care reform in Washington D.C., has asked one question: How do we pay for health care? But the real question is: How do we fix the health care system? Addressing the epidemic of too much medical care (which doctors believe represents 21% of all medical care delivered) is a practical solution. My own medical experiences have reminded me that the problem is not just administrative waste, it’s clinical waste as well that’s driving up the health care costs for everyone.”
Part 3 - Redesigning Health Care (Makary analyzes less well-known reasons why health care costs are increasing, from Pharmacy Benefit Managers to quasi-ethical Wellness Programs at work.)
11. The author introduces several companies who are focused on re-designing health care using a relationship-based model of care: Iora Health, ChenMed, and Oak Street Health.
12. Price transparency is a necessary prerequisite to any health care reform, particularly considering price transparency yields quality transparency.
13. Health care brokerage (an industry notorious for trade secrets, predatory retention, and misaligned sales incentives) is a flaw analogous the the brokerage of CDOs which resulted in the financial crisis of 2007. Makary proposes self-insuring as well as finding "Rosetta certified" brokers as a solution.
14. Many people don't know that Pharmacy Benefit Managers exists, and they exist as yet another racket within health care. The goal of a PBM is to increase the spread, or the difference in amount between what they pay a pharmacy and what they invoice a health plan for medication. The PBM keeps any rebates the drug manufacturers or pharmacists offer, and many times the PBMs are owned by the health insurance company they work for (thus increasing the profit margin). “The PBMs have gone to great lengths to keep real prices secret, using a fog of fees, rebates, and discounts that make a true value too complicated for anyone to determine. Even if an employer figured out the spread on a few medications, there are thousands of these meds and they go by different names, have different comparables, different generics, different schedules, and different dosages - and each combination of these variables is priced differently.”
15. Makary summarizes the chapter himself: “The conflicts of interest inherent in the modern GPO (Group Purchasing Organization) business model continue to limit innovation, drive up prices, and cause unacceptable shortages for the most basic drugs and medical supplies.” Group Purchasing Organizations are the middlemen who purchase hospital supplies, and those GPOs may not even be in the same state as the hospital for whom they are acting.
16. Wellness committees are invasive, quasi-ethical, and have no scientific credibility with respect to commonplace health metrics. The employment of wellness committees nationwide can be attributed to pseudoscience, governmental support, and the illusion of employee benefits.
17. Medical schools should evolve to teach more holistic and care-centered medicine as opposed to rote memorization. Our public discourse about health care should match the perceived realities instead of distancing us from the issue.
Like any expose on American health care, Makary's book is frustrating. It's frustrating because powerful forces have designed an unwinnable game that Americans are obligated to play. He concludes his book with a call to action, both for those within the medical field and without, though he has a special call for those within medicine considering they are to do no harm, therefore it is their ethical responsibility to change the system. Though the system is broken, Makary does a good job including reasons to be optimistic in every chapter. He regularly cites specific doctors and clinics that are doing their best to provide quality care focused on a different, more appropriate understanding of what "care" means. I had no issue with Makary's quality of writing, and the book moved quickly and was full of excellent passages to note. The lack of politics within this book cannot be understated or over-appreciated.
I'll borrow from The Wire and conclude with the following: "We used to heal people in this country. Now we just put our hand in the next guy's pocket."
November 22, 2019
This should be required reading for ALL adults. Should be read at least annually by all employed int the "health care industry."
According to the US Bureau of Labor Statistics, employment in the "health care industry" is projected to grow by 14% over the next 10 years. Their reasoning is based on our "aging population" fueling demand.
Several months ago, I called my insurance company to ask a question. The little gal sort of answered it... mostly I didn't understand. It concerned a "facility fee" charge for a fully covered X-ray. While I explained to her that it was done in the same building that housed my doctor's office, I just didn't understand. NO Facility in Birmingham, Alabama keeps their X-ray equipment out in a field somewhere without electricity, she said I still had to pay the silly $ 74.00 bill. Then she went on to tell me that my policy would pay in full if I were to get a mammogram. NO! NO! NO! Just NO!
I do not ever want another mammogram. I had one once and I swore never again. Well Okay then,
your insurance plan will cover in full the cost of a colonoscopy. Same answer as before but louder. Than I hung up before she could inform me of other "benefits" my plan covered.
There is no history of either breast or colon cancer in my family. While I'm likely to die of something..... (absolutely guaranteed to die), it will likely be something else.
This was an easy read, yet horrifying indictment of our current medical system. While I received this book from the library, I am also ordering from Amazon to keep as a future reference guide.
According to the US Bureau of Labor Statistics, employment in the "health care industry" is projected to grow by 14% over the next 10 years. Their reasoning is based on our "aging population" fueling demand.
Several months ago, I called my insurance company to ask a question. The little gal sort of answered it... mostly I didn't understand. It concerned a "facility fee" charge for a fully covered X-ray. While I explained to her that it was done in the same building that housed my doctor's office, I just didn't understand. NO Facility in Birmingham, Alabama keeps their X-ray equipment out in a field somewhere without electricity, she said I still had to pay the silly $ 74.00 bill. Then she went on to tell me that my policy would pay in full if I were to get a mammogram. NO! NO! NO! Just NO!
I do not ever want another mammogram. I had one once and I swore never again. Well Okay then,
your insurance plan will cover in full the cost of a colonoscopy. Same answer as before but louder. Than I hung up before she could inform me of other "benefits" my plan covered.
There is no history of either breast or colon cancer in my family. While I'm likely to die of something..... (absolutely guaranteed to die), it will likely be something else.
This was an easy read, yet horrifying indictment of our current medical system. While I received this book from the library, I am also ordering from Amazon to keep as a future reference guide.
March 8, 2020
A book everyone should read. The author tells all about healthcare in the United States of America. The language is common and the logic is common sense. He reveals it all in great detail. He is bringing conscience and morality into the discussion about healthcare, its policies, its financing and its games.
This book is a short, concise and critically important revelation of a major arena everyone will encounter. It is absolutely shameful that this book is not mentioned in every news story, talk show and political event in the country. The money at stake is probably the only reason it is not.
PLEASE READ THIS BOOK!
This book is a short, concise and critically important revelation of a major arena everyone will encounter. It is absolutely shameful that this book is not mentioned in every news story, talk show and political event in the country. The money at stake is probably the only reason it is not.
PLEASE READ THIS BOOK!
November 28, 2021
I almost quit reading this book after the first two or three chapters. Makary's style of writing seemed rather imprecise to me, and having read numerous articles by Atul Gawande, another physician-author who writes impeccably - I was turned off by Makary. (Despite exemplary credentials, as an accomplished surgeon and assiduous researcher at Johns Hopkins University.) It seemed like he levels blanket charges against aspects of the health care system without identifying that there is a range of practices - some good and some unconscionable - among hospitals, physicians, middlemen, pharmacy benefit managers, and pharmaceutical companies. (Well, maybe not PBMs and pharmaceutical companies!)
As I got past my dissatisfaction with style, however, I began to see that he had correctly diagnosed the major issues in the health care finance system that result in frequent inappropriate and unnecessary care as well as prices that are often predatory, especially as applied to those who can least afford it.
He addresses examples of:
- hospitals suing patients for collection and garnishing their wages
- unnecessary cesarean sections primarily for the convenience of the obstetrician
- lack of transparency in pricing and inability to get an estimated price prior to having a procedure
- wildly variable and absurdly high pricing for identical helicopter transfers
- excessive prescription of opioids (at one point, looking in the mirror at his former approach to prescribing 30 days' supply following surgery)
- out-of-network price gouging, resulting in surprise billing and balance billing that are subject to Congressional scrutiny at the moment
- opaque pricing models by pharmacy benefit managers (PBMs) that result in unjustifiable prices charged for medication)
- lack of transparency in the way medical professionals communicate with patients (using medical jargon when straightforward and simpler language would improve understanding)
Makary's recommendations is that we all take charge of our own health, question physicians or hospitals when they suggest a procedure, and demand a price estimate prior to undergoing a procedure. Speaking directly to me as a hospital trustee, he also suggested that trustees make sure they understand how the institution's pricing model works, how the hospital's charity care program is constructed, and how unpaid bills are handled (in terms of collection activities).
To me, the one thing that patients can do that didn't receive sufficient attention is to engage in healthy lifestyles that reduce the need for the healthcare system in the first place. We all know what is needed: eating healthy, unprocessed foods; getting regular exercise and adequate sleep; managing stress; avoiding smoking; and managing the use of substances that can be destructive if overused (alcohol, drugs).
I was glad I stuck with the book, notwithstanding my misgivings in the beginning.
As I got past my dissatisfaction with style, however, I began to see that he had correctly diagnosed the major issues in the health care finance system that result in frequent inappropriate and unnecessary care as well as prices that are often predatory, especially as applied to those who can least afford it.
He addresses examples of:
- hospitals suing patients for collection and garnishing their wages
- unnecessary cesarean sections primarily for the convenience of the obstetrician
- lack of transparency in pricing and inability to get an estimated price prior to having a procedure
- wildly variable and absurdly high pricing for identical helicopter transfers
- excessive prescription of opioids (at one point, looking in the mirror at his former approach to prescribing 30 days' supply following surgery)
- out-of-network price gouging, resulting in surprise billing and balance billing that are subject to Congressional scrutiny at the moment
- opaque pricing models by pharmacy benefit managers (PBMs) that result in unjustifiable prices charged for medication)
- lack of transparency in the way medical professionals communicate with patients (using medical jargon when straightforward and simpler language would improve understanding)
Makary's recommendations is that we all take charge of our own health, question physicians or hospitals when they suggest a procedure, and demand a price estimate prior to undergoing a procedure. Speaking directly to me as a hospital trustee, he also suggested that trustees make sure they understand how the institution's pricing model works, how the hospital's charity care program is constructed, and how unpaid bills are handled (in terms of collection activities).
To me, the one thing that patients can do that didn't receive sufficient attention is to engage in healthy lifestyles that reduce the need for the healthcare system in the first place. We all know what is needed: eating healthy, unprocessed foods; getting regular exercise and adequate sleep; managing stress; avoiding smoking; and managing the use of substances that can be destructive if overused (alcohol, drugs).
I was glad I stuck with the book, notwithstanding my misgivings in the beginning.
May 29, 2025
The Price We Pay: What Broke American Health Care—and How to Fix It by Marty Makary, MD explores the myriad ways that patients in the United States healthcare system are shaken down to their last pennies by greedy hospitals, doctors, insurance companies, predatory health screenings, surprise bills, financial and procedural waste in the medical industry, opaque and confusing billing practices, over-prescription of medications, overtreatment of pain, and more. Dr. Makary, a surgeon and research leader at Johns Hopkins, travels across the country, confronting many of these unethical practices head-on and exposing them to us, the laymen, in this frankly shocking read. He also explains "the game," in which hospitals and insurance companies are always competing for the biggest discounts and secret pricing with one another while ensuring their pockets always continue to stay heavily lined.
The book provides many examples of Americans who struggle to make ends meet, who must cut costs elsewhere or pick up second jobs to afford their health care costs, and who cannot afford to build savings or retirement funds because of those expenses. Even more shockingly, it investigates numerous hospitals suing their patients—including non-profit hospitals, who are supposed to be held accountable by law to provide charitable care to those patients who are unable to afford services. They cheat this law by providing things such as nutrition pamphlets and exercise tips, stating that this qualifies as the charitable care required to maintain their tax exempt status.
Dr. Makary also advocates strongly for transparent billing practices, shoppable quotes for elective procedures, laws addressing wage garnishment for unpaid medical expenses and other predatory medical debt collection practices, and monitoring doctors' performance of clinically appropriate procedures. He gives examples of facilities or companies already modeling these concepts that have seen great success to prove to skeptics that it can be done while still producing profits for those oh-so-precious shareholders controlling the strings (not that this should be the priority of the healthcare industry, but this is Late Stage Capitalism in America, baby! What did you expect?) He also highlights the physician response to learning more about the own appropriateness of their clinical performances when compared to others in their field.
I enjoyed learning about this topic during this read. Although I am absolutely horrified at the figures and examples presented in this book, I can't say that I am surprised. As a healthcare worker myself, I am grateful for this read for exposing some of the dangerous practices that I can now warn my patients to be aware of and avoid. I think all healthcare workers and providers should read this book to learn how to best advocate for their patients to receive fair prices and adequate care, and question those around us when we see them pushing for unnecessary procedures, adding mysterious charges to the bill, or exhibiting any other questionable behaviors that may put their patients at risk financially, emotionally, and even, in some cases, physically. When we put profits above our patients, we are violating basic morals and standards that the medical world should be proud to uphold.
ETA Dr. Makarty has been espousing some questionable information. Not sure really what to think of him anymore or if that would influence my opinion on this book. It was written before the pandemic and before he joined the Trump administration.
The book provides many examples of Americans who struggle to make ends meet, who must cut costs elsewhere or pick up second jobs to afford their health care costs, and who cannot afford to build savings or retirement funds because of those expenses. Even more shockingly, it investigates numerous hospitals suing their patients—including non-profit hospitals, who are supposed to be held accountable by law to provide charitable care to those patients who are unable to afford services. They cheat this law by providing things such as nutrition pamphlets and exercise tips, stating that this qualifies as the charitable care required to maintain their tax exempt status.
Dr. Makary also advocates strongly for transparent billing practices, shoppable quotes for elective procedures, laws addressing wage garnishment for unpaid medical expenses and other predatory medical debt collection practices, and monitoring doctors' performance of clinically appropriate procedures. He gives examples of facilities or companies already modeling these concepts that have seen great success to prove to skeptics that it can be done while still producing profits for those oh-so-precious shareholders controlling the strings (not that this should be the priority of the healthcare industry, but this is Late Stage Capitalism in America, baby! What did you expect?) He also highlights the physician response to learning more about the own appropriateness of their clinical performances when compared to others in their field.
I enjoyed learning about this topic during this read. Although I am absolutely horrified at the figures and examples presented in this book, I can't say that I am surprised. As a healthcare worker myself, I am grateful for this read for exposing some of the dangerous practices that I can now warn my patients to be aware of and avoid. I think all healthcare workers and providers should read this book to learn how to best advocate for their patients to receive fair prices and adequate care, and question those around us when we see them pushing for unnecessary procedures, adding mysterious charges to the bill, or exhibiting any other questionable behaviors that may put their patients at risk financially, emotionally, and even, in some cases, physically. When we put profits above our patients, we are violating basic morals and standards that the medical world should be proud to uphold.
ETA Dr. Makarty has been espousing some questionable information. Not sure really what to think of him anymore or if that would influence my opinion on this book. It was written before the pandemic and before he joined the Trump administration.
November 30, 2019
This was a frustrating read. The data was good; the analysis and conclusions, not so much.
The good parts: The data and stories about how much we pay, the inaccessible chargemasters, the opaque billing, CEOs who don't know their ass from their elbow and claim ignorance of how their hospitals operate. Dr. Makary does a great job of showing many of the ways in which the system fails.
The bad: Trying to analyze the situation and draw political conclusions. Makary is a fan of price transparency. I'm not opposed to that, per se, but he doesn't address the myriad limitations to the problem. Once your care costs enough, it is immaterial to you whether it's $30K or $50K; you've hit your maximum. Second, you don't always have the ability to do research, either because it's urgent or because the patient is generally incapable. The issue of pushing the burden onto patients isn't really addressed. Third, lack of competition. One of the highlighted stories is in Carlsbad, NM, where the local hospital has a record of suing for unpaid bills. The next nearest hospital is in Roswell, an hour away. That's usable for some people some of the time, but for other people and times, Carlsbad's hospital has a captive market. With increased consolidation in healthcare, transparency will be only so useful as a tool.
He's also a little overly generous about the motivations of doctors and administrators, which is interesting considering his opening story about predatory surgeons promoting unnecessary surgery. Doctors respond to incentives, both good and bad.
To his credit one segment is about improvement at the hospital level, by using data to improve surgical outcomes. However, in some cases he's prone to tossing off anecdotes. For example, that providing price data for deliveries meant "everyone" selected the cheaper hospital, with "no loss of quality." It's worth noting that the example was in Boston, where Partners Healthcare has been accused of driving costs up at the most prestigious hospitals. I know from personal and friends' experience that even when price data is available, that the more expensive option may be chosen because of real or perceived differences in quality or other factors. (For example, I chose to deliver in a more distant hospital because I preferred its maternal-fetal medicine team, and would have done so even if it had cost more.)
He also talks up companies self-insuring and the use of health shares without mentioning downsides (self insured companies are exempt from the requirements of the Affordable Care Act; health shares do not guarantee payment).
It's a shame because the basic data gathered is really interesting; he just doesn't know where to go with it.
The good parts: The data and stories about how much we pay, the inaccessible chargemasters, the opaque billing, CEOs who don't know their ass from their elbow and claim ignorance of how their hospitals operate. Dr. Makary does a great job of showing many of the ways in which the system fails.
The bad: Trying to analyze the situation and draw political conclusions. Makary is a fan of price transparency. I'm not opposed to that, per se, but he doesn't address the myriad limitations to the problem. Once your care costs enough, it is immaterial to you whether it's $30K or $50K; you've hit your maximum. Second, you don't always have the ability to do research, either because it's urgent or because the patient is generally incapable. The issue of pushing the burden onto patients isn't really addressed. Third, lack of competition. One of the highlighted stories is in Carlsbad, NM, where the local hospital has a record of suing for unpaid bills. The next nearest hospital is in Roswell, an hour away. That's usable for some people some of the time, but for other people and times, Carlsbad's hospital has a captive market. With increased consolidation in healthcare, transparency will be only so useful as a tool.
He's also a little overly generous about the motivations of doctors and administrators, which is interesting considering his opening story about predatory surgeons promoting unnecessary surgery. Doctors respond to incentives, both good and bad.
To his credit one segment is about improvement at the hospital level, by using data to improve surgical outcomes. However, in some cases he's prone to tossing off anecdotes. For example, that providing price data for deliveries meant "everyone" selected the cheaper hospital, with "no loss of quality." It's worth noting that the example was in Boston, where Partners Healthcare has been accused of driving costs up at the most prestigious hospitals. I know from personal and friends' experience that even when price data is available, that the more expensive option may be chosen because of real or perceived differences in quality or other factors. (For example, I chose to deliver in a more distant hospital because I preferred its maternal-fetal medicine team, and would have done so even if it had cost more.)
He also talks up companies self-insuring and the use of health shares without mentioning downsides (self insured companies are exempt from the requirements of the Affordable Care Act; health shares do not guarantee payment).
It's a shame because the basic data gathered is really interesting; he just doesn't know where to go with it.
December 17, 2020
I learned a lot from the book. His research is varied and pulls the curtain back on a lot of aspects of the health care industry. However, his tone almost made the book unreadable. Between poignant dialogue that no human being has ever said and inserting himself unnecessarily into stories or situations at every chance, I found myself rolling my eyes throughout the book. His position is more than clear (biased to a point) and points out alarming facts, but he too often relies upon anecdotal events or evidence that *he* has deemed acceptable. I wish the voices of the dozens of people he interviewed came through stronger than *his* observations about these people. This book felt like a really long patronizing mansplain that never really made its point. Surely Dr. Makary doesn’t think that individual actions on the part of the patient will fix the health care system. And yet, that’s exactly the point he makes time and again, never questioning the foundation of the system he and his prestigious hospital stand upon. Which is ironic, because all his interviews show how the system time and again crushes individuals across the country. And not all of us are lucky enough to have an elite John’s Hopkins surgeon to call the CEO of a hospital for us to get us out of a bill (a story he relays in different contexts a few times). He clearly sees himself as the hero of the story, and that’s his biggest problem.
December 26, 2019
In this book, Marty Makary takes the reader on a quick tour of the broken American health care system. The main culprits in his mind are excess/unnecessary care, administrative bureaucracy (e.g. insurance companies, insurance brokers, hospital supplies, billing departments, etc.), and general complexity and lack of transparency stemming from such a complicated system with so many stakeholders.
It is quite obvious that many of these issues are pet-projects for Dr. Makary as he has done great work by creating advocacy groups and spreading awareness around some of these issues. However, I believe he has provided very little justification that his arguments are the true drivers of health care costs at large. For example not once did Dr. Makary mention the outrageous cost of medical school & malpractice insurance. Nor did he mention America's strong patent laws on prescription drugs, the doctor shortage (b/c med school is so hard to pass!), or doctor salaries. Only in passing did Dr. Makary mention differences between the American system and other advanced economies.
Dr. Makary does a fair job at pointing out legitimate problems in the health care system. His position can be summarized as the following: get rid of the middleman, increase transparency, deliver the right care at the right time. That's it. Overall the book is very approachable and enjoyable to read. Dr. Makary uses a lot of examples and personal stories to drive the narrative, which I found helpful. I did learn a lot and I think he has a valuable message. But if you are looking for a book that will dive into the complexities of the American health care system and politics you won't find it here. This book is about trimming the fat on the existing system from a health care professional's point of view. It does nothing to question the fundamentals of American health care (e.g. employer-sponsored health insurance).
It is quite obvious that many of these issues are pet-projects for Dr. Makary as he has done great work by creating advocacy groups and spreading awareness around some of these issues. However, I believe he has provided very little justification that his arguments are the true drivers of health care costs at large. For example not once did Dr. Makary mention the outrageous cost of medical school & malpractice insurance. Nor did he mention America's strong patent laws on prescription drugs, the doctor shortage (b/c med school is so hard to pass!), or doctor salaries. Only in passing did Dr. Makary mention differences between the American system and other advanced economies.
Dr. Makary does a fair job at pointing out legitimate problems in the health care system. His position can be summarized as the following: get rid of the middleman, increase transparency, deliver the right care at the right time. That's it. Overall the book is very approachable and enjoyable to read. Dr. Makary uses a lot of examples and personal stories to drive the narrative, which I found helpful. I did learn a lot and I think he has a valuable message. But if you are looking for a book that will dive into the complexities of the American health care system and politics you won't find it here. This book is about trimming the fat on the existing system from a health care professional's point of view. It does nothing to question the fundamentals of American health care (e.g. employer-sponsored health insurance).
February 1, 2021
Everyone should read this book! The American health care system is broken and this book does a great job of explaining it.
February 12, 2022
A really powerful book and a searing exposé on the healthcare industry in America. I knew that the healthcare industry wasn’t great, but I didn’t know it was this bad. There are some horrifying stories and jaw-droppers. The lack of transparency, price gouging, middlemen, secret kickbacks and the overall business model of the healthcare industry are really depressing and infuriating.
This book contains very important information and ways the healthcare industry could improve — and what we as individuals can do. I really respect the author’s passion. As a surgeon, Dr Makary is doing so much to improve the system.
Be warned, however, that this book is not for when you want to have a good mood.
This book contains very important information and ways the healthcare industry could improve — and what we as individuals can do. I really respect the author’s passion. As a surgeon, Dr Makary is doing so much to improve the system.
Be warned, however, that this book is not for when you want to have a good mood.
October 19, 2023
I’ve been trying to understand our healthcare system better and I really enjoyed the use of stories to keep the book engaging. It def helped me understand the crazy lack of billing transparency in healthcare and shady relations with insurance companies that need to change. I didn’t read it cover to cover because it’s not necessary but I think I’ll return to it again :)
September 10, 2019
***I was granted an ARC of this via Netgalley from the publisher.***
The Price We Pay: What Broke American Health Care – And How To Fix It by Marty Makary, looks at the reasons why healthcare costs for Americans are out of control and the ways in which people are working to change the way we fundamentally structure healthcare and focus more on the patient than profits. In this book, he looks at many areas where patients are being price gouged and taken advantage of. This includes the high cost and in transparency of the cost of care in hospitals, doctors doing unnecessary procedures and the way the compensation for insurance brokers, pharmacy benefit mangers and group purchasing organizations does not benefit the people they provide service to but themselves. But while pointing out the failings in America's healthcare system, Makary also points to examples of positive changes that the healthcare community should take note of and strive to emulate. Through a mix of personal stories from his own experience as a doctor, Americans struggling to pay their medical bills and people in the industry trying to improve how we conduct medical care, Makary reveals the inner workings of a system many find bewildering and hostile and shows us ways it can change for the better.
Read my full review here:
https://openlettersreview.com/posts/t...
Rating: 5 stars. Would highly recommend to a friend.
The Price We Pay: What Broke American Health Care – And How To Fix It by Marty Makary, looks at the reasons why healthcare costs for Americans are out of control and the ways in which people are working to change the way we fundamentally structure healthcare and focus more on the patient than profits. In this book, he looks at many areas where patients are being price gouged and taken advantage of. This includes the high cost and in transparency of the cost of care in hospitals, doctors doing unnecessary procedures and the way the compensation for insurance brokers, pharmacy benefit mangers and group purchasing organizations does not benefit the people they provide service to but themselves. But while pointing out the failings in America's healthcare system, Makary also points to examples of positive changes that the healthcare community should take note of and strive to emulate. Through a mix of personal stories from his own experience as a doctor, Americans struggling to pay their medical bills and people in the industry trying to improve how we conduct medical care, Makary reveals the inner workings of a system many find bewildering and hostile and shows us ways it can change for the better.
Read my full review here:
https://openlettersreview.com/posts/t...
Rating: 5 stars. Would highly recommend to a friend.
November 19, 2020
Agree with the conclusion (i.e., that healthcare in America, as far as costs go, needs fixing) and even some of the premises (e.g., one major problem is the lack of transparency in pricing, another is the gap between provider and consumer), but somewhat disagree with how author and MD Marty Makary gets the reader there. Most of the book uses emotional appeals in the form of anecdotal hard-luck stories to lambast / shame various hospitals, pharmas, or other providers for charging or trying to collect on admittedly egregious bills. In my humble and uninformed opinion, this misses the mark by focusing too much on a symptom and not the root causes (though they are briefly addressed). Still, the last chapter does provide some very limited advices about certain actions the average person can take.
December 8, 2021
This book by Dr. Makary presents incredible insight into the predatory and nonsensical buisness performed everyday in the world of healthcare. It is alarming to me that Marty and his team alone were able to uncover the myriad problems displayed in the book and I hope that this book will spur more research into the problems run rampant in healthcare. I really enjoyed this book and will have to give it another read very soon. I highly reccomend this book to anyone interested in why our healthcare system is so terrible, especially if you are a current or aspiring medical professional.
July 10, 2021
A wonderful book by Marty Makary of John Hopkins. Many descriptions--and even better explanations--about the different parts of of health care system with more than a few recommendations on how to improve the parts that don't function so well. It even includes an explanation of how helicopter/ambulances have been misused as a money making opportunity. But its focus is really on the basics ... like why some hospitals routinely overcharge patients and then take them to court while others operate much more ethically. And it has one of the best explanations I've seen of why the price for medicines is so hard to figure out. He even explains why mail order is rarely your best option. Finally Makary explains why the doctors we have in our system have virtually no training in how to work together and with other medical staff.
In reading this book, you will be very frustrated as Makary reveals all the problems ... but you will also be hopeful as he gives examples of hospitals, doctors, and other parts of our health system have figured out better ways to deliver a better product to patients.
In reading this book, you will be very frustrated as Makary reveals all the problems ... but you will also be hopeful as he gives examples of hospitals, doctors, and other parts of our health system have figured out better ways to deliver a better product to patients.
December 19, 2020
An absolute must read for a country where the majority of bankruptcies are from excessive medical bills. We're fed crap about fearing and loathing "socialized" medicine, which is basically what virtually every other first world civilized country has to one degree or another (and the US quietly has a bit of its own, but the politicians don't want us to know that). So we've been brainwashed and trained to hate commies and socialists and everything except free market capitalism. Except free market capitalism is failing the vast majority of Americans so quickly, badly and permanently, the concept of a middle class will soon exist only in history books. I certainly think little of Marx and his ilk. I think that's been more than proven as a failure. I've spent my whole life hearing about the evils of "socialist medicine" like you'll find in Canada. Why is it so evil? Cause you'll have long wait times, they'll raise your taxes, you won't have options, the healthcare will be inferior.
Okay, my response. Long wait times? Longer than the US? I waited 13 goddamn months to see a neurologist I was referred to and because I have so many neurological problems, he (like most doctors I see) declared himself overwhelmed, he had to spend time reviewing my medical history, and to make an appointment for 12 months later. My wife and I were aghast, because I have serious disorders and I desperately needed a couple of minor brain surgeries and had been largely incapacitated waiting months and months to see him with the expectation these would be set up. Nope. Another example. This involves both time and competence. In 2016, I developed severe stomach and abdominal problems, so much so that if I touched any food, the nausea and pain were indescribable and crippling. Considering I already had what is viewed as the most painful disease "known to mankind," commonly called "the suicide disease," that's saying a lot. So I made an appointment with a GI, had to wait forever, had the usual tests which showed nothing so he dumped me. I demanded more tests. Just because the first one didn't show anything didn't mean my symptoms went away, yet that's how 80% of my doctors acted. One test, find nothing, goodbye. Assholes! To shorten it, it took 2 and a 1.2 YEARS of me going from specialist to specialist, undergoing over 30 tests, being sent to some of the best hospitals around the country while I starved, losing over 175 lbs in less than two years. If I ate anything, I puked and suffered for hours. My wife kept me alive with a few bites of baby food every few days. Finally, after all of the doctors had given up, I started doing my own extensive research, and then testing and experimenting on myself -- not for the first or third time -- and ultimately determined the cause, so I wrote up a 20-page paper with data, resources, results, etc., met with several specialists, and turned out I was right. I had a pancreatic disease, which those morons never considered testing. No options? What options do we have here? I have to take the insurance I can get. I have little practical choice over deductible, because if I want to choose something actually affordable, the damn premium is not at all! And historically, many haven't covered most pre-existing conditions, some dump you if you come down with too many problems, most of the time you still have insane expenses, and meds? ONE of my essential generic pancreatic medications costs more in one month than I make. So I can't afford it and have gone back to suffering. Meanwhile, some of my doctors have encouraged me to get some meds from Canadian pharmacies, so while one of my meds isn't even covered by my insurance here but I could pay retail of something like $600 for a third of a month, I can get three months of the same thing from a Canadian pharmacy for less than $125! Yeah, socialized medicine is freaking evil! Anti-American. You know why it's considered anti-American? Because the bozos brainwashing us over the past decades are all making a KILLING off the US healthcare and pharmaceutical industries and they'll use any propaganda, any manipulation to keep the system the way it is, even though it's killing and breaking us. Higher taxes? Less than going bankrupt because we can't afford higher damn medical costs! You think about that. Again, we've been so brainwashed into believing taxes are evil - despite the fact that no government can run without them - that we don't want to pay any, even if it hurts us. Which it is. I don't have all day, so I'll end before I want to with one final example. When I was young, my father worked in Canada for several years. We moved there from New England, and later moved back to the mid-Atlantic region. While there, I contracted a very serious disease that, back in those days, could be terminal. I was placed in a special hospital, completely quarantined, and given regular, personal treatment and attention 24/7/365. My parents lived hundreds of miles away and I got to see them on my birthday. I was there for a year and a half. In America, my parents would have been so broke, so destitute for life, so devoid of hope even though I survived, simply due to the I'm sure MILLIONS of dollars in medical bills that incurred. Many resort to suicide. But you know how much my parents were forced to pay for all of that? NOTHING! Not one damn cent! And THAT is the evil of socialized medicine while I have been seriously ill here in the US for over a dozen years, have spent millions and lost nearly everything I have paying fucking CO-PAYS, when if I were still in Canada, I wouldn't have spent crap. Oh the evils the other countries face...
We're damn idiots! This book doesn't go quite where I went, but I wanted to emphasize its importance to all of us, and supplement it with some of my own tales. I advise everyone to read it. The system is more than broken here. It's time for a massive fix. Recommended!
Okay, my response. Long wait times? Longer than the US? I waited 13 goddamn months to see a neurologist I was referred to and because I have so many neurological problems, he (like most doctors I see) declared himself overwhelmed, he had to spend time reviewing my medical history, and to make an appointment for 12 months later. My wife and I were aghast, because I have serious disorders and I desperately needed a couple of minor brain surgeries and had been largely incapacitated waiting months and months to see him with the expectation these would be set up. Nope. Another example. This involves both time and competence. In 2016, I developed severe stomach and abdominal problems, so much so that if I touched any food, the nausea and pain were indescribable and crippling. Considering I already had what is viewed as the most painful disease "known to mankind," commonly called "the suicide disease," that's saying a lot. So I made an appointment with a GI, had to wait forever, had the usual tests which showed nothing so he dumped me. I demanded more tests. Just because the first one didn't show anything didn't mean my symptoms went away, yet that's how 80% of my doctors acted. One test, find nothing, goodbye. Assholes! To shorten it, it took 2 and a 1.2 YEARS of me going from specialist to specialist, undergoing over 30 tests, being sent to some of the best hospitals around the country while I starved, losing over 175 lbs in less than two years. If I ate anything, I puked and suffered for hours. My wife kept me alive with a few bites of baby food every few days. Finally, after all of the doctors had given up, I started doing my own extensive research, and then testing and experimenting on myself -- not for the first or third time -- and ultimately determined the cause, so I wrote up a 20-page paper with data, resources, results, etc., met with several specialists, and turned out I was right. I had a pancreatic disease, which those morons never considered testing. No options? What options do we have here? I have to take the insurance I can get. I have little practical choice over deductible, because if I want to choose something actually affordable, the damn premium is not at all! And historically, many haven't covered most pre-existing conditions, some dump you if you come down with too many problems, most of the time you still have insane expenses, and meds? ONE of my essential generic pancreatic medications costs more in one month than I make. So I can't afford it and have gone back to suffering. Meanwhile, some of my doctors have encouraged me to get some meds from Canadian pharmacies, so while one of my meds isn't even covered by my insurance here but I could pay retail of something like $600 for a third of a month, I can get three months of the same thing from a Canadian pharmacy for less than $125! Yeah, socialized medicine is freaking evil! Anti-American. You know why it's considered anti-American? Because the bozos brainwashing us over the past decades are all making a KILLING off the US healthcare and pharmaceutical industries and they'll use any propaganda, any manipulation to keep the system the way it is, even though it's killing and breaking us. Higher taxes? Less than going bankrupt because we can't afford higher damn medical costs! You think about that. Again, we've been so brainwashed into believing taxes are evil - despite the fact that no government can run without them - that we don't want to pay any, even if it hurts us. Which it is. I don't have all day, so I'll end before I want to with one final example. When I was young, my father worked in Canada for several years. We moved there from New England, and later moved back to the mid-Atlantic region. While there, I contracted a very serious disease that, back in those days, could be terminal. I was placed in a special hospital, completely quarantined, and given regular, personal treatment and attention 24/7/365. My parents lived hundreds of miles away and I got to see them on my birthday. I was there for a year and a half. In America, my parents would have been so broke, so destitute for life, so devoid of hope even though I survived, simply due to the I'm sure MILLIONS of dollars in medical bills that incurred. Many resort to suicide. But you know how much my parents were forced to pay for all of that? NOTHING! Not one damn cent! And THAT is the evil of socialized medicine while I have been seriously ill here in the US for over a dozen years, have spent millions and lost nearly everything I have paying fucking CO-PAYS, when if I were still in Canada, I wouldn't have spent crap. Oh the evils the other countries face...
We're damn idiots! This book doesn't go quite where I went, but I wanted to emphasize its importance to all of us, and supplement it with some of my own tales. I advise everyone to read it. The system is more than broken here. It's time for a massive fix. Recommended!
February 6, 2022
It’s not terribly well written but very informative (and infuriating). Worth listening to it! I find myself wondering why he has not once proposed that we look at how other, socialist countries manage their healthcare - a big believer in markets
April 13, 2023
Wow. A true call to action for healthcare leaders. I hope we can strive to achieve some of the change that this author calls us to!
July 26, 2020
Imagine you are going to get an oil change for your car. You ask an employee how much it will cost, and they tell you they can only tell you after they've completed the service. When you get your oil change, you get a bill for $10,000, and if you don't pay you will get sued, collections will come after you, your credit score will get hit, and some money will be taken out of every pay check until the bill is paid. That is the current american healthcare system as it stands in much of the country.
This book should be a must read for every adult american. It can literally save you thousands of dollars. Dr. Makary really dives deep into the issues of american healthcare, and he uncovers a lot of appalling facts about the system. Like many things in life, healthcare is extraordinarily complicated. However, the system as it is now is unsustainable, and at the end of the day the people who are paying the most are the american taxpayers.
In this book, he discusses our for-profit healthcare system, unethical medical practices, price gouging, price transparency and the lack thereof, insurance companies and brokers, pharmaceutical companies, unethical legislature that enforces the status quo, measures that can be taken to change the system, alternatives to the system, and much more.
Rarely have I learned so much and been so shocked by a book before. The business aspect of medicine is a topic I knew very little about, but after reading this book I feel much more well-versed in the field despite the shock of what I learned. This book makes me much more passionate about being part of the solution to the american healthcare crisis that we are all paying the price for.
If you've ever wondered why american healthcare is so much more expensive than that of other developed nations, or why your insurance premiums seem to go up every year, or if you're dealing with a healthcare issue yourself, or if you're simply curious about how the healthcare system in america works, this book is a must-read.
This book should be a must read for every adult american. It can literally save you thousands of dollars. Dr. Makary really dives deep into the issues of american healthcare, and he uncovers a lot of appalling facts about the system. Like many things in life, healthcare is extraordinarily complicated. However, the system as it is now is unsustainable, and at the end of the day the people who are paying the most are the american taxpayers.
In this book, he discusses our for-profit healthcare system, unethical medical practices, price gouging, price transparency and the lack thereof, insurance companies and brokers, pharmaceutical companies, unethical legislature that enforces the status quo, measures that can be taken to change the system, alternatives to the system, and much more.
Rarely have I learned so much and been so shocked by a book before. The business aspect of medicine is a topic I knew very little about, but after reading this book I feel much more well-versed in the field despite the shock of what I learned. This book makes me much more passionate about being part of the solution to the american healthcare crisis that we are all paying the price for.
If you've ever wondered why american healthcare is so much more expensive than that of other developed nations, or why your insurance premiums seem to go up every year, or if you're dealing with a healthcare issue yourself, or if you're simply curious about how the healthcare system in america works, this book is a must-read.
January 7, 2020
A timely follow-up to Rosenthal’s American Sickness and other books that examine the U.S. health care system at a macro level. Marty provides an on the grounds look at lesser-known drivers of health care spend: insurance brokers, PBMs, GPOs. He criticizes various hospital practices, including surprise billing and wage garnishing, which contradict the “do no harm” mantra of medicine. He admonishes the outsiders: the air ambulance companies and private equity firms that have infected health care and seek to profit as out-of-network enterprises. He even critiques medical education on the whole, urging educators to focus less on the rote memorizing and more on what truly matters to patients. I found myself nodding along, though occasionally wondering how certain findings (e.g., outlier doctors get paid more for performing more reexcisions) could be so bewildering to his clinical audiences.
Unfortunately Marty’s viewpoint as an academic physician, at times, feels constrained. He is strangely unwilling to discuss Medicare for All or any broader health reforms that entail a public payer - one that could restrain price gouging, limit surprise medical bills, and cut middlemen as he so desires. Hell, why not cut reimbursement rates across the board? Instead, Marty’s proposed reforms (e.g., changing insurance broker compensation to flat fees, require spread transparency for PBMs) are small-scale and mild, suggesting that he is reluctant to fully butt heads with his medical colleagues and community for the sake of his cause. This is the biggest downside to this book and what differentiates Makary from Rosenthal. The latter is former MD who, no longer tied to medicine, works freely as an opinionated journalist and writes like one too.
Unfortunately Marty’s viewpoint as an academic physician, at times, feels constrained. He is strangely unwilling to discuss Medicare for All or any broader health reforms that entail a public payer - one that could restrain price gouging, limit surprise medical bills, and cut middlemen as he so desires. Hell, why not cut reimbursement rates across the board? Instead, Marty’s proposed reforms (e.g., changing insurance broker compensation to flat fees, require spread transparency for PBMs) are small-scale and mild, suggesting that he is reluctant to fully butt heads with his medical colleagues and community for the sake of his cause. This is the biggest downside to this book and what differentiates Makary from Rosenthal. The latter is former MD who, no longer tied to medicine, works freely as an opinionated journalist and writes like one too.
October 11, 2020
This was an excellent book—a must read for everyone!! I fully expected it to be reading a book about politics and healthcare reform, but instead got a book about (wait for it) HEALTHCARE! I learned so much and am left both horrified and hopeful. There is so much change that can happen, even before it gets to the legislative level. I really appreciated the emphasis on the need for transparency in pricing and how healthcare can and should operate like other businesses while being a place of healing and real charity for anyone who needs it (without killing them financially later). This book did not have a partisan bias, just a rally cry for all Americans. The author had a very casual and conversational tone which might turn off some, but I found it very easy to read, especially having no experience in a healthcare profession. I felt like I was in a class with a fun professor who truly loves what he teaches and has a sincere desire for change.
February 16, 2020
This book needs to be required reading for every American!
June 2, 2022
every doctor, politician, health care worker, student, employer, & parent - every AMERICAN - should read this book. as someone who knew next to nothing about health care or insurance or hospital fees, i didn’t expect to enjoy this book, and yet i could not put it down. dr. makary’s writing style is easy to read, approachable, honest, relatable, and funny, all while explaining complex concepts and processes in a confusing system. and he even offers practical advice for what individual people like you and i can do to combat the twisters, expensive american health care system. i feel like i am finally starting to understand a world that was previously shrouded in mystery, and i feel empowered to do something to help the honest, vulnerable people who are attacked by american health care every day. perhaps what i found most refreshing was dr. makary’s honesty and humility; though a doctor himself, he never hesitated to point out ways his own industry and practice needs reform. he never points the finger of blame at other people for the sake of saving face, but rather discusses practical forms with honesty for the sake of helping individual people gain quality healthcare and financia stability. and he doesn’t just point out the problems and leave his readers hopeless, but he offers inspiration and advice from around the globe to encourage us and spur us onward to change for the better. if you feel frustrated by the american health care system: you’re not alone. this book is a chance to expose its cracks and begins to work toward reform. dr. makary’s ideas are changing the nation and i feel honored he wants us to be a part of it.
July 26, 2023
this book was both a deep dive into American healthcare, and also in-part, a memoir of Dr. Makary's life as he uncovered dirty undersides of the American healthcare system and worked to right these wrongs.
in my opinion, this book was one of the easiest topical books I've read. Dr. Makary's writing draws you into the issues and connects readers so well to the issues and how they impact us all. I actually got emotional reading about the legal and financial burdens put upon an entire community in New Mexico.
I knew the American healthcare was messed up, but I thought that was mostly because of coverage and insurance issues. I didn't truly know why or how bad it could be. And this book reveals multiple levels and perspectives, from insurance companies, to hospital structures, doctor prescriptions, employee benefits, and so much more.
I think this book will start a string of books in my reading, looking more into the hospital and healthcare system.
in my opinion, this book was one of the easiest topical books I've read. Dr. Makary's writing draws you into the issues and connects readers so well to the issues and how they impact us all. I actually got emotional reading about the legal and financial burdens put upon an entire community in New Mexico.
I knew the American healthcare was messed up, but I thought that was mostly because of coverage and insurance issues. I didn't truly know why or how bad it could be. And this book reveals multiple levels and perspectives, from insurance companies, to hospital structures, doctor prescriptions, employee benefits, and so much more.
I think this book will start a string of books in my reading, looking more into the hospital and healthcare system.
February 16, 2023
2.5 stars
this book gives a solid high level overview of all the components of the healthcare system from an expert in the field, and there were so many relevant and heartbreaking first hand accounts of ways the system is failing communities across the board
but those are pretty much the only positives. in an attempt to make this accessible or more like a novel, the author uses really random transitions that offer nothing to his overall message and got really annoying. about halfway through, he stops relying on scientific evidence and seems to really rely on anecdotal evidence from his own experience to make his points. and while there were micro solutions offered or shared, there was no systematic solution or commentary based on all his research, aside from 2 sentences dismissing ACA.
decent overview, but not the comprehensive and unbiased read i was hoping for.
this book gives a solid high level overview of all the components of the healthcare system from an expert in the field, and there were so many relevant and heartbreaking first hand accounts of ways the system is failing communities across the board
but those are pretty much the only positives. in an attempt to make this accessible or more like a novel, the author uses really random transitions that offer nothing to his overall message and got really annoying. about halfway through, he stops relying on scientific evidence and seems to really rely on anecdotal evidence from his own experience to make his points. and while there were micro solutions offered or shared, there was no systematic solution or commentary based on all his research, aside from 2 sentences dismissing ACA.
decent overview, but not the comprehensive and unbiased read i was hoping for.
March 3, 2022
Makes you really mad about the state of US healthcare if you weren't already burdened by medical expenses. I can't believe we just allow healthcare providers to charge whatever they want without regulation. While I think price transparency may help, I don't think many patients really have the privilege of shopping around, especially if its an emergency or geographical restrictions. Not everyone can just drive an hour to a provider that is cheaper. Free market principles don't work when there is no freedom of choice.
March 6, 2023
An informative summary of the US healthcare system, with evidence-backed claims and forward-looking solutions. A must read for anyone who uses American healthcare in any capacity
Topics to remember - billing transparency, private equity involvement, necessity for a competitive market, unnecessary health screens, group purchasing orgs, healthcare brokers, pharma benefit management, value-based medical education, tldr- implement strategy to correct incentives
Topics to remember - billing transparency, private equity involvement, necessity for a competitive market, unnecessary health screens, group purchasing orgs, healthcare brokers, pharma benefit management, value-based medical education, tldr- implement strategy to correct incentives
October 4, 2024
I learned more about the insane administrative bloat and amount of middlemen getting paid off in healthcare. Why is it that we don't know the cost of a surgery before getting it done and hospitals can charge literally whatever they want? Just because they can. I truly don't know what to do with pursuing a degree that is supposed to heal people but ends up ruining them financially (hello, social determinants of health).
This book argues for price transparency and a subsequent free market for hospitals, which is a good first step. No mention of socialized healthcare, which is weird and off-putting.
Books written in the first person that talk about "disrupting" things are not my favorite nor most reliable sources.
This book argues for price transparency and a subsequent free market for hospitals, which is a good first step. No mention of socialized healthcare, which is weird and off-putting.
Books written in the first person that talk about "disrupting" things are not my favorite nor most reliable sources.
February 3, 2025
I didn't know it at first, but Dr. Marty Makary isn't your ordinary run-of-the-mill doctor. To say he is an overachiever would be a huge understatement since he has his toes in not only in surgical oncology and gastrointestinal laparoscopic surgery, but also he conducts public health research, advocates for reform in healthcare and a return to patient centered care. He is grounded, well-informed, active, extremely keen, principled, driven, efficient, and awesome. In short, this book is a critique on the state of the healthcare industry in 2019. Interestingly, he was warning the public about deficiencies in medical supply chains, primarily with personal protective equipments, long before COVID hit American shores.
Thanks to him, I learned more about:
- price gouging for services at hospitals partly caused by inflated prescription/equipment costs handed down to us and shoved up our asses by middlemen called pharmacy benefit managers (PBM) and group purchasing organizations (GPO) (hospitals are complicit in this tacit multiparty agreements with insurers and manufacturers/pharmacies are bound by NDA's)
- predatory billing practices where hospitals go after former patients through "wage garnishment"
- prevalence of overtesting, overdiagnosing, over-prescribing, conducting unnecessary procedures
Fun fact, he is apparently our nominee for the Food and Drug Administration. Awesome!
Thanks to him, I learned more about:
- price gouging for services at hospitals partly caused by inflated prescription/equipment costs handed down to us and shoved up our asses by middlemen called pharmacy benefit managers (PBM) and group purchasing organizations (GPO) (hospitals are complicit in this tacit multiparty agreements with insurers and manufacturers/pharmacies are bound by NDA's)
- predatory billing practices where hospitals go after former patients through "wage garnishment"
- prevalence of overtesting, overdiagnosing, over-prescribing, conducting unnecessary procedures
Fun fact, he is apparently our nominee for the Food and Drug Administration. Awesome!
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