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PUMPING IRONY: Doctor’s Orders

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Doctor's Orders

A former practicing physician explores the bottom-line priorities that govern our dysfunctional healthcare system — and offers some practical tips for overcoming the many obstacles it throws in our paths.

I got a call the other day from the clinic where I get my ears cleaned every year or so. The woman on the other end of the line told me I needed to come in to get my blood pressure checked. I demurred. Elisabeth Rosenthal, MD, would agree.

In her new book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Rosenthal warns us that such interactions are motivated more by business considerations than by patient well-being. “In the past quarter-century, the American medical system has stopped focusing on health or even science,” she writes. “Instead it attends more or less single-mindedly to its own profits.”

Rosenthal, editor-in-chief of Kaiser Health News and a former practicing physician, offers a blistering critique of our ailing healthcare industry that should serve as a warning, particularly to seniors who believe their doctors have only their patients’ best interests in mind when making treatment decisions. In fact, it’s economics that generally rules the medical market, she argues. And those forces have transformed what was once a patient-centered practice into a cold-blooded industry whose operating principles can be boiled down into 10 decidedly bottom-line rules:

  • More treatment is always better. Default to the most expensive option.
  • A lifetime of treatment is preferable to a cure.
  • Amenities and marketing matter more than good care.
  • As technologies age, prices can rise rather than fall.
  • There is no free choice. Patients are stuck. And they’re stuck buying American.
  • More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
  • Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
  • There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
  • There are no standards for billing. There’s money to be made in billing for anything and everything.
  • Prices will rise to whatever the market will bear.

Rosenthal calls out all the usual suspects — rapacious insurance companies, expansionist hospitals, Big Pharma, greedy medical specialists — and some less obvious culprits, including medical-device manufacturers, billing contractors, and even research institutions. She doesn’t spare fans of single-payer solutions, either, pointing out that Medicare may have been more of a boon to doctors than to their patients.

“Employer-provided insurance plans produced a significantly higher rate of growth, and Medicare blew the walls out,” surgeon Richard Patterson, MD, told Rosenthal. “Doctors suddenly had the wherewithal to invest heavily in the stock market and shopping centers, to buy airplanes and island retreats.”

That’s because physicians who once allowed patients to pay whatever they could afford were suddenly collecting “98 percent of the charges they billed, and insurers, including Medicare, went on paying ‘usual and customary’ fees by locality for years after — hardwiring high payments into our bills,” Rosenthal writes. “Many still do.”

I’m about as skeptical as they come when dealing with doctors and hospitals, but some of the anecdotes Rosenthal offers — especially those involving the elderly — left me pretty much speechless. Take the case of Barbara Baxter, who had both her hips replaced in her 50s. When she developed a problem with her right hip several years later, she sought the advice of her doctor, who told her that replacing it with a new device would have a “92 percent chance of success.”

The healthcare industry works hard to convince consumers that its procedures are safe and its outcomes assured, but Rosenthal notes that there’s no sure thing when replacing a joint. “Orthopedics is not a high science like neurology,” she writes. “It is frequently something more akin to precision carpentry.”

Sure enough, two weeks after her surgery, Baxter heard a loud pop in her hip. The implant had fractured a crucial bone structure, leaving her in excruciating pain. What followed, however, probably caused her even more discomfort.

An orthopedist suggested that a bone-growth stimulator placed on her skin might help the fracture heal more quickly, without requiring another surgery, which Baxter wanted to avoid. Her insurance company wouldn’t cover the cost of the device, but the hospital offered to lease it to her for $10,000. She told her doctor she couldn’t afford it, so he said he could get it for her for $7,000. She tracked down someone at the manufacturer, who offered one for $5,000. But she had only $1,778 in her health savings account, she said. “We’ll take it,” he replied.

“Doctors, device manufacturers, and drugmakers worry endlessly about the fear of huge payouts for malpractice suits,” Rosenthal writes. “But more often it is patients who not only live with but also bear the financial consequences of bad results and problematic devices.”

Months later, during a routine doctor’s appointment, Baxter learned that her original hip-implant device, the one still holding her left hip together, had been recalled. The letter stated that the company was under no legal obligation to notify patients. It offered no apology.

As brutal as Baxter’s experience was, doctors were at least trying to remedy an actual health problem. That’s often not the case, Rosenthal argues. She cites a University of Texas study that showed Medicare recipients receive more colonoscopies than necessary. “This procedure kills people, especially old people,” study author James Goodwin, MD, told her. “It knocks them off for several weeks. They have incontinence. They can’t get to the bathroom. It’s humiliating.”

Mohs surgery has become similarly popular among the Medicare set in recent years. The procedure treats basal cell carcinomas, slow-growing benign lesions that don’t metastasize. Despite little evidence suggesting the surgery is more effective than cheaper treatment options, the use of this procedure grew by 700 percent between 1992 and 2009, Rosenthal reports. The reason, she explains, is pretty clear — and quite cynical. “The big difference between these more pedestrian treatments and Mohs is the price tag: hundreds of dollars versus more than $10,000 or even $20,000 for Mohs. Mohs surgery is often followed by plastic surgery to correct the skin defect.”

Then there’s the emergence in recent years of home evaluation companies like CenseoHealth, which offer “house calls” to the elderly. Rosenthal relates the case of one such visit to a resident of an upscale retirement community. He’d received a “limited-time offer” for a free in-home physical by a doctor who just happened to be in the area. The examination showed him to be in excellent health, though he “might benefit from some testosterone to combat fatigue.”

This is nothing like the house calls of yesteryear, she notes. Because the government pays private insurers’ monthly fees based on the “burden of illness” of Medicare Advantage recipients, insurance companies hire firms like CenseoHealth to solicit appointments with elderly patients in an effort to raise the “risk scores” so they can collect higher fees.

“In his pitch to the insurance plans that hire his company, Jack McCallum, MD, a cofounder of CenseoHealth, says they typically can count on getting $2,000 to $4,000 more per person from Medicare, because home visits may uncover a new illness or tease out a new complaint that will send the risk score upward,” Rosenthal writes.

She prescribes plenty of bold remedies for what ails our healthcare system (everything from alternative financing of medical education and more aggressive regulation of insurance plans to reforming medical billing standards and revamping the drug-patent process). She also offers some valuable tips for any individual trying to navigate the medical minefields. I was particularly heartened, however, by her embrace of a decidedly old-school virtue: patience.

“The healthcare industry spends nearly $15 billion on advertising annually to encourage worry,” she writes. “That’s good business, but not smart medicine.”

At my age, any routine check-up is liable to reveal some symptom (high blood pressure, for instance) that invites further investigation or a trip to the pharmacy. I used to think this was just a case of well-intentioned doctors looking out for my well-being. I could decide whether to take their advice, but they were basically just trying to do their job. Rosenthal makes a pretty strong argument for skepticism on that front. They’re more likely trying to generate revenue.

“The value of so-called watchful waiting is taught in medical school, but it is terrifically underused in American medicine because it isn’t at all profitable,” she explains. “The ‘Do something!’ strategy prevails. But scans aren’t always helpful. Each one sets off a cascade of treatment, and they often detect ‘junk’ — incidental insignificant findings — unrelated to your symptoms.”

I’ve seldom been one to follow doctor’s orders, but Rosenthal’s prescription for maintaining good health in a dysfunctional medical system is one we might all be wise to heed: “Don’t rush to the doctor. Give your body a chance to heal.”

, an Experience Life deputy editor, explores the joys and challenges of aging well.

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