How to Make a Killing: Blood, Death and Dollars in American Medicine

by Tom Mueller

How did a lifesaving medical breakthrough become a for-profit enterprise that threatens many of the people it’s meant to save? Six decades ago, visionary doctors achieved the the humble kidney, acknowledged since ancient times to be as essential to life as the heart, became the first human organ to be successfully replaced with a machine. Yet huge dialysis corporations, ambitious doctor-entrepreneurs and Beltway lobbyists soon turned this medical miracle into an early experiment in for-profit medicine―and one of the nation’s worst healthcare catastrophes. With powerful insight and on-the-ground reporting, New York Times best-selling author Tom Mueller introduces an unforgettable cast of characters. Heroic patients, including a Hollywood stuntman and body double, risk their lives to blow the whistle on how they’ve been mistreated. An unpaid activist living in a south Georgia trailer park fights to save patients from involuntary discharge from their lifesaving care. Industry insiders put their careers on the line to speak out about the endemic wrongs and pervasive inequality they’ve witnessed―and about dialysis executives who dress as musketeers and Star Wars characters to exhort their employees to more aggressive profit-seeking. Mueller evokes the scientific ingenuity and optimism of the 1950s and 1960s, when the burgeoning field of organ transplant and early dialysis machines offered long-awaited hope for lifesaving care. That is, until a New York salesman had himself dialyzed on the floor of the House, and Congress made renal disease the only “Medicare for All” condition―opening the financial floodgates for Big Dialysis. Of the thousands caught in a web of corporate greed, a disproportionate number are Black and Latino, highlighting the stark racial divides already endemic to American medicine. How to Make a Killing reveals dialysis as a microcosm of American medicine and poses a vital find a way to fix dialysis, and we’ll have a fighting chance of fixing our country’s dysfunctional healthcare system as a whole, restoring patients, not profits, as its true purpose.

Genres: Nonfiction, Medicine, History, Science, Politics, Health, Audiobook

288 pages, Hardcover

First published August 1, 2023

About the author

Tom Mueller writes for The New Yorker and other publications. He lives in a medieval stone farmhouse surrounded by olive groves in the Ligurian countryside outside of Genoa, Italy.

see also
http://www.truthinoliveoil.com/

Reviews

[Hema Karunakaram · Rating 5 out of 5]

Must-read for anyone who works in the renal industry or anything adjacent, and for anyone with CKD (or a loved one with CKD). It seems most negative reviews are coming from people who 1) haven’t read the book and are inappropriately reviewing the summary, or 2) profit from this industry.

I have worked in this industry a few years and learned so many nuances in this book that I didn’t understand before. The writing meanders a little and it’s clear the author is new-ish to the space, but it’s very well researched and informative. Having worked in the industry, there are a lot of stories that are hard to read — but I have no doubt they are true. Dialysis is a difficult and often heartbreaking process, and patients deserve so much more than what the industry in the US is providing them.

[Barbara · Rating 4 out of 5]

I had to read this in short sessions because I became so enraged at how terrible our corporate for profit system of health care is. This well researched book focuses on the big dialysis companies and their ruthless search for money and blatant disregard of best practices for their captive patients.

[Hannah · Rating 4 out of 5]

This was so horrifying and fascinating that I thought several times, "Surely I must be getting a very one-sided look at this issue?" I've literally never thought about dialysis before and now it haunts me.

[Sarah Marie · Rating 4 out of 5]

Interesting read about how for-profit dialysis centers have come to be one of the most prolific healthcare problems nationwide, as profits are put before patient care, causing needless harm and even death to many patients. It wasn't terribly long, which I appreciated.

[Diane · Rating 1 out of 5]

From the initial description of this book, the author’s viewpoint seems rather lop-sided and I worry that people will interpret it as being from a scientific standpoint - which it is not, based on the author’s credentials. Dialysis is a life-saving medical treatment that serves as VITAL to individuals with kidney failure -- I've had personal experience with this in my family. To call it "one of the nation’s worst healthcare catastrophes" is hyperbolic at the least.

[Kevin Schnurr · Rating 5 out of 5]

As someone who performed both hemodialysis and peritoneal dialysis over the course of two years while waiting for a life-saving kidney transplant, this historical and contemporary assessment of the dialysis industry was very insightful. I’ve witnessed first-hand many of the horrors described in this book. Renal patients deserve better and the clock is ticking for many of them.

[Laura · Rating 3 out of 5]

Not my usual fare, but this is a dissection about dialysis, the creation of it, the operation of it, and the current corporations running it. I have to admit I'm a little biased, but it's hit or miss. The history and science is a 10/10, but everything else seems very one-sided.

[Logan Christina · Rating 4 out of 5]

3.75

It took me a little while to get into this book - for the first 50% it was like I was reading but was I digesting what I was hearing??? sorta thing but throughout the whole book I was so disheartened by this reality of our healthcare. I do feel I have come out knowing more about dialysis.

A few key takeaways:
1. This reality is so infuriating and saddening.
2. Greed has NO PLACE in healthcare.
3. The American healthcare system has totally lost the plot.
4. It should be illegal for non-hospital employees (ie. Drug or pharma sellers) to be in the rooms of patients.

Thoughts while reading:

25% It’s so crazy that this is still a question: is healthcare a fundamental right versus something that should be monetized.

30% it’s really interesting to think of the moral implications of medicine, transplants, or a program like dialysis - should they be able to stop their own treatment - if so, would it be considered suicide?

37% it’s interesting to learn that dialysis had such an impact on the way our entire US healthcare system - it was the starting point for for profit care

38% I feel so smart listening to this lol ~am I better than everyone??~

44% I will say this book is hard to get stuck into - like it’s easy to go in and out and it feels like you haven’t missed anything? Idk I feel like I’m reading this but am I really taking it in???

All in all this book is a glaring reminder that greed has no place in the world of healthcare.

48% “yes, they’re keeping them alive but at what cost to their quality of life?”

57% so many of their “debates” seem so common sense - do this thing that is better for the patience or do this thing that cost more money and is worse for the patience??? Hmmmm

I feel like I hadn’t really gotten into this book until now - 60% of the way in

72% - comparing Devita to Animal Farm - wow rough

72% corporate America is the woat. GREEDDDDDD

74% the casualness in which BILLIONS of dollars is discussed in relation to payouts is crazy crazy

[L. · Rating 1 out of 5]

Highly inaccurate propaganda against the dialysis industry. Mueller takes nuggets of truth and spins them into lies. He falsely accuses the dialysis industry of malfeasance and low quality but he does not suggest how it can be changed or improved. Don’t waste your time on this book.

[Sanjay Banerjee · Rating 4 out of 5]

The book narrates how the dialysis care for End Stage Renal Disease (Kidney Failure) Patients is broken in the US Healthcare System driven by the profit motive of ‘For Profit’ Dialysis Clinics. What is true for Dialysis care is also true for the US Healthcare system in general where the profit motive vs patient centricity has led to spiralling and uncontrolled expenditure on healthcare while clinical outcomes have lagged far behind. As I had worked in this sector sometime during the course of my career, I could relate to the issues raised in the book. Incidentally, while the context of dialysis care is different in our country, profit centricity vs patient centricity of Corporate Hospitals also often engender similar issues as narrated in the Book.

[Meg · Rating 4 out of 5]

I was a HUGE fan of EXTRA VIRGINTY many years ago so, I jumped right into this. It's a Medical/Business expose with tons of crazy characters as well as ordinary people. I tore through this. If you need dialysis, you've got to hope you have REALLY good insurance and probably a strong advocacy team on your side. Whoa.

[Rebecca Baker · Rating 5 out of 5]

An in-depth look at the perils of for- profit medicine and why it doesn't fit with the Hippacrattic oath. I promise, you will be shocked at the blatant disregard of what's best for patients, when profits come into play.

[Melissa Rochelle · Rating 4 out of 5]

I found this to be a thorough investigation into for-profit treatment. The medical industry is so driven by profits that patients are often forgotten. It can often feel like no one is in it for patient care anymore, it's all about making the most money. The book offers history into how dialysis came to be, documents accounts of patient harm, shares public information from testimony before Congress from the companies and patients, and much more.

[Noah Markewitz · Rating 4 out of 5]

200 page John Oliver episode about all the ways greed and money have fucked over dialysis patients. Really well written, and inspiring for a young aspiring nephrologist to do better.

[Jerusha]

Interesting and skewed take on dialysis in America. The vast majority of healthcare in this country is for profit, so to position dialysis as the leading problem is biased. The biggest differentiator is that dialysis is government funded which, in my opinion, all healthcare should be. The author regularly refers to money spent by patients, which compared to other types of healthcare, is pretty limited.

The book implies that people are on dialysis because a dialysis clinic has moved into the area based on the racial makeup of the residents. Systemic racism is definitely a factor for who ends up with kidney failure, but the clinic is a response to that, not a cause. Removing the clinic won’t make less people need it.

Top execs making really large profits is the norm in most healthcare settings, including dialysis. I agree that this needs to change and more of that money would end up on patient care in a non-profit world. The entire system is broken, but that’s not the fault of one portion of the industry.

Aside from all my above (and many other) issues with the content of the book, the writing also wasn’t great. The chapters are all over the place without telling a cohesive story. The author talks about a dialysis advocate and mentions her trailer home no less than 3 times during the book, including at the end to let us know she’s in a nicer home now. Completely irrelevant and pretty insulting. He also wraps up with an attempt to tie this back to other cultural issues we’re facing, along with the inability for people to end their own lives. This has no relevance and just further sensationalizes the topic.

[Helen K Lutkiewicz · Rating 1 out of 5]

Bs book

It is a bunch of bs. Not the financial stuff with the gov and meds. But the removal of pts from clinics, lack of care and vaccinations. Treating pts poorly. All bs.

[Davis Lee · Rating 1 out of 5]

I wonder how many dialysis clinics this billionaire stepped into ? Talking about making a killing, kinda weird that Tommy boy wrote a book on dialysis and not something like big pharma.

[Walt · Rating 4 out of 5]

This book offers a microcosm of the rot at the heart of the American Dream.

Mueller deftly navigates the toxic nexus of for-profit healthcare by keeping focused on the niche aspect of dialysis. He shows how doctors and researchers from the 1950s-1970s sought to provide a game-changing technology to help all Americans; and how that was corrupted by simple greed. Mueller presents his case in the most emotional and heart-wrenching case possible, but his the dark picture he creates is all too easy to believe. He is not a rightwing nut spewing lies about lizard people voting for Democrats, he provides a lot of documentation for further study.

Dialysis was created to replace the kidneys. Patients often visit a clinic 3 times per week. The original doctors and researchers who developed dialysis wanted at-home care. But it was and remains much more expensive than clinic-based practice. They were able to convince Congress to cover funding for all dialysis - one of those government guaranteed payouts. Here was the root of the problem.

Mueller shows how Wall Street took to dialysis with a fast food approach. Quantity over quality. The idea was to get patients in and out at quickly as possible and for the most money. Medicare covers dialysis; but they negotiate their prices (frowny face). Private insurers pay more. So right away there are questions about prioritized patients. There are also all sorts of ways to cut corners that are very much life-threatening. Over the years there has been push-back against the consolidation in the industry, but those have been relatively unsuccessful.

Mueller is definitely biased and the book is full of emotional appeal with first-hand accounts of captive patients struggling for survival. The brush he paints with may be too biased. It is hard to tell. Every story has a villain and Mueller focuses on Kent Thiry the long-time head of DaVita Analysis. Mueller portrays him a lot like Elon Musk or any other eccentric billionaire. I can easily envisage any Wall Street tycoon leading in similar fashion. Dialysis is not the only industry that feels that legal settlements and punitive judgements are just one more cost of doing business. There are other villains in the book, who add new forms of corruption and greed to the story. But it is not unexpected.

The Sackler Family receives a lot of blame and criticism for the opioid epidemic. They were an even smaller microcosm of the healthcare system. But they used tactics very similar to what Mueller describes in the dialysis market. Doctors paid to publish pro-industry articles and push patients to certain clinics, regulatory agencies hiring industry insiders to monitor those industries, and lobbyists to influence decision makers in government. It is more of the same. The ingenuity and brazenness of the conflict of interest is not that surprising. What is a bit surprising is how many nephrologists are tainted by the system. Kickbacks through a quasi-independent third party gets around inconvenient kickback laws.

There is a lot of fiery talk in this book. One of the most impressive aspects of the book is the documentation. Unlike many exposes, Mueller references a lot of scholarly journals discussing the effect fast-food dialysis has on patients, to counter industry claims that their standards and turnaround times come from evidence-based best practices. There are a lot of first-hand accounts, legal briefings, and government reports. The documentation is nearly one-third of the book. However, the references are not fully cited. It will still take a dedicated reader to track the articles and reports down with only a title and possibly authors and dates.

Overall, it is a fascinating look at one corner of the American Healthcare Hellscape. Mueller compares American dialysis with dialysis in other western countries. The outcomes and quality of life are very, very different. The consolidation of dialysis into 2 mega corporations allows for additional abuses over captive patients. Although there is not enough documentation, it appears that the two firms coexist happily, probably like other forms of healthcare. The writing and organization are easy to read and digest. It is not too short and not too long. It is not too complicated, and not too confusing. There are a preponderance of alphabet soup and jargon that is at times difficult to follow. But the main idea of being a case study in American healthcare with its weaknesses in allocating resources, ethical behavior, greed, informed consent, patient rights, and related questions are on display.

[Ashlyn Goold · Rating 3 out of 5]

My interest in this book was sparked by watching the "Painkillers" docuseries on Netflix about Purdue Pharma's role in the opioid epidemic. The corruption that exists in the dialysis industry is as unsettling as Purdue's negligence. Tom Mueller shares how a profit-focused approach to healthcare has negatively impacted the quality of life and treatment of dialysis patients. He shares how dialysis companies cut corners (shortening treatment times in the spirit of quantity over quality, under-staffing clinics, improper sanitation of equipment, poor enforcement of quality regulations, etc.) to maximize profits. In addition to exposing the shortcomings of Big Dialysis, Mueller suggests that in order to regain balance, we as a society need to do more to protect the most fragile among us, rather than exploiting their weaknesses. In short, if my kidneys fail, I'll be moving to Australia.

"I've begun to see America's many problems as a progressive loss of homeostasis. That we allow some of our most defenseless citizens to be herded together and bled for profit... Some dialysis patients I've met are like those folktale figures who have lost the most, who yet have the most to give; the legendary ones with every reason to be bitter about the course of their lives, who yet savor life's sweetness... Listening hard to dialysis patients in America, caring for them honorably and well, is a way to regain our collective homeostasis. Being more like (dialysis patients) is a path to finding our better selves."

[Elena J · Rating 5 out of 5]

How to Make a Killing by Tom Mueller is a searing exposé of how one of medicine’s greatest miracles the ability to replace a failing kidney with a machine devolved into a cautionary tale of corporate greed, political corruption, and human cost.

With the precision of a journalist and the empathy of a storyteller, Mueller unravels the evolution of the dialysis industry from its hopeful beginnings in the 1950s to its transformation into a multibillion-dollar empire where profit too often takes precedence over patient care. Through powerful firsthand accounts whistleblowers, activists, doctors, and patients he reveals the devastating consequences of treating life itself as a commodity.

Mueller’s narrative is both investigative and deeply human. The pages pulse with stories of resilience: a Hollywood stuntman risking his life to expose malpractice, an activist in rural Georgia fighting to protect the vulnerable, and insiders who jeopardize their careers to reveal the truth. Each voice underscores the moral urgency of a system where lives hang in the balance between compassion and capitalism.

Part medical history, part moral reckoning, How to Make a Killing is journalism at its finest a book that forces readers to look at what happens when the pursuit of healing collides with the pursuit of profit. It’s not just an exposé on dialysis; it’s a mirror reflecting the state of American healthcare itself.

Essential, haunting, and impossible to ignore.

[Chris Schwab · Rating 5 out of 5]

Over a twenty year span I've seen all kinds of articles and series of articles exposing the goings-on in kidney dialysis. From 2010's Propublica series of articles "Dialysis: High Costs and Hidden Perils of a Treatment Guaranteed to All" to 2020's Scientific American series "Profit and Loss: America on Dialysis" they have run the hellscape of modern US kidney dialysis.

The above are just a couple of very fine "fire starters" that are out there. Now NYT's best-selling author Tom Mueller has thrown a log on that fire with his book! His in-depth analysis and stories of heroes fighting this for-profit scourge give us even deeper insight into how a field of medicine can go so wrong.

And being the father of a daughter dealing with kidney disease for over twenty years (transplant now) and a Kidney Dialysis Advocate (been active at the Colorado State Legislature), I can vouch for it's accuracy.

[Brenda Kochis · Rating 5 out of 5]

There are many stories out there about the problems in for-profit healthcare. In this book Tom Mueller focuses on the issues that arise when there are just two main companies that dominate the dialysis industry, primarily DaVita and Fresenius. In the search for more profit, Mueller documents the shortcuts that these companies take, essentially shorter dialysis times and more rapid input of dialysate and the unfortunate use of a parameter such as Kt/V. Additionally, home dialysis was generally not encouraged. He liberally documents those who are harmed not only by these policies, but also those who are blackballed using unsavory techniques since many are on government programs that pay for this. Those who can afford the more expensive insurance receive better care, essentially a rationing of dialysis services.
This is an eye opener expose of the effects of kidney treatments by the profit sector.

[Dan Trontz · Rating 1 out of 5]

I agree with a few of the other comments here. I gotta say, this seems to be a full-blown attack on medical breakthroughs. He's talking about kidney dialysis – an undeniable lifesaver – as some sort of national catastrophe? That's definitely way over the top.

Sure, there might be big companies profiting from it, but I think that’s true in all industries. Feels like he's hunting for villains in the wrong place.

And I mean, is he suggesting we need to "fix dialysis" to save our healthcare system? Dialysis is a life-changer for tons of people. Instead of demonizing it, let's appreciate the good it's doing. It might not be perfect, but calling it one of the worst healthcare catastrophes? Seems like a serious stretch. I hope this book is more balanced than I think it will be.

[Susie Murray · Rating 4 out of 5]

An important book for anyone anyone working in nephrology or with dialysis patients in the United States.

The book is timely and important, but not without its own splashes into what feel like lurid sensationalism, either. Dialysis tech is not a position that I believe should really exist, as those positions are better held by trained nurses. Nevertheless, the insinuations in this book that dialysis techs are all pain-inflicting sociopaths, patrolling the blood floor and conspiring with their corporate overlords to murder unruly patients, stretches credibility and is iy nsulting to a group who are by-and-large well meaning and doing their best for their patients.

Still, the accusatons of forced discharges are troubling and warrant further investigation.

[Kyle McCormick · Rating 1 out of 5]

I’m no stranger to Mueller’s previous works but after reading the summary and description I’ve got a raised eyebrow. How does someone go from writing about Olive Oil to medicine!

The upcoming book seems to dance a fine line between insightful critique and exaggerated hyperbole. I think it’s key to remember that Mueller is not a practicing medical professional nor an expert, and his bold pronouncement of certain medical practices, which have helped many lives, as national health disasters strikes me as irresponsible.

While I’m sure the book will have some good insight, I can’t help but feel a sensationalism slant may overshadow the credibility of his work.

[Colton Johnson · Rating 1 out of 5]

Tom Mueller’s work is normally pretty good. I’m a big history buff and I love to travel so I’ve always known him to be a good travel author since I read a lot of National Geographic. But after reading this book's description, I’m a little puzzled as to why he decided to write about a completely different topic. Personally, I think these medical advancements have done great things for people, especially those in my family. I agree with a few of these other comments. To call them national health disasters just feels wrong. I hope he goes back to writing more about different expeditions and historical findings. That’s where he excels, not healthcare, unfortunately.

[Dr. Ashori · Rating 5 out of 5]

As a doctor it wouldn't be wise for me to comment on this book but if you read this book to understand how a diagnosis can be financialized then you'll take a lot away from it. If you read it just to think that the whole healthcare industry is evil and corrupt then you'll be unnecessarily jaded. If you read this and conclude that dialysis is bad then your health literacy might be too low to digest such content. I doubt any corporation is evil but just as physicians are held fiduciary to the patient it without a doubt that corporations have to follow an even higher standard when they are holding far more power than the doctor.

[Mauri · Rating 4 out of 5]

Enlightening book for me. Though having working in a dialysis clinic for 13 years I did not see or hear inappropriate patient terminations or abusive treatment by staff. I felt the ESRD network was far more interested in assisting patients than the book described. There was always a push for home dialysis treatment by clinic staff . The author made a compelling case for home hemo and peritoneal treatments. I was blessed to work with a clinic administrator who cared about the patients and strongly encouraged staff to do the same. That said some of the situations the author described were discouraging and heartbreaking.

[Carrie · Rating 4 out of 5]

I rarely read books like this because as a physician I’m at the point in life where you don’t want to think about work outside of work- but this book is enlightening and well done and I’m glad I read it. The history of dialysis is fascinating and certainly life changing. But the American way of medicine doing business has corrupted it over the years and I hope
We can still turn it around. I am saddened for my patients who have endured suffering because of the failures of this system. We can do better. Prevention, early detection and discussion is key.

[Christine Black]

I do believe this is a good informative book about the dialysis monopoly. I think anyone with friends or loved ones on dialysis should read for a deeper understanding of what patients go thru. Buy I got half way thru chapter two and couldn’t ho on. It hits really close to home if you are a current dialysis patient. He hits on real topics but fears I always have. Being hurt because you spoke up or being blackballed and being labeled a threat and are kicked out of treatment even though you will die in 3 weeks without it. Recommend. Hut not fir me