Book review: “The Price We Pay” by Marty Makary

How to pay for healthcare has become one of the defining issues of our time. Some try to dismiss these worries as out of order, citing the quality of our healthcare comes with an understandable price, or pointing out the large lines in countries that have been claimed by shudder socialized medicine. On the other side, Medicare for All has become a rallying cry, in an attempt to cement health care as a human right. But Dr. Marty Makary, in his book The Price We Pay tackles what I think gets more to the heart of the problem. Instead of asking how to pay for healthcare, Dr. Makary asks Why is healthcare so expensive in the first place? And that question has a really long answer.

I really like Dr. Makari’s book, because he doesn’t point to a single scapegoat that can answer for all of healthcare’s problems. But you have to start somewhere, and his first example is rather telling. He begins by pointing out the faults of doctors. He tells of a common practice by some doctors to perform unnecessary vascular leg surgeries on patients. Narrowing of the leg arteries is something that naturally occurs with age, but your body adapts. Most patients don’t need surgery at all. Yet surgeons set up screenings (that they call “free” health care services) to catch as many new patients as they can, and then make $10,000 per surgery. This is a very lucrative business. Dr. Makari discusses with a fellow doctor how these doctors can get away with this:

I asked Chatrathi how the doctors convince patients to undergo the procedures.

“They ask people, ‘Do you have leg pain?'” he replied with a smirk.

Nudges from doctors can be as powerful as IV sedation. Sometimes we steer patients toward what’s best for them. Sometimes we steer patients toward what’s best for us.

You would hope that your doctor’s main concern is your health, and that other interests aren’t at stake in your care. We trust our health care professionals. But trust is eroding in our healthcare system, and has been some time. Unnecessary procedures are just one of the things causing your health care premiums to rise. Dr. Makari points to the lack of transparency in healthcare costs allowing hospitals to charge absolutely outrageous prices, the markup-discount game between hospitals and insurance companies, a burgeoning bureaucracy of healthcare administrators, predatory billing practices, outside forces like helicoptor ambulance companies that aren’t constrained by regulations, insurance brokers who get kickbacks from insurance companies, and middlemen like pharmacy benefit managers (PBMs) and Group Purchasing Organizations (GPOs).

In one telling introduction, Dr. Makari describes his experience at a car dealership:

Walking into a care dealership puts a knot into the pit of my stomach. I feel cheapened by the whole experience. I know that I will have to haggle with the salesperson, as the sticker price is never the real price. I will endure the silly playacting (“Let me see what my manager can do”). Even if I walk out with a good deal, I leave feeling ambushed, frazzled.

Isn’t it sad that you can get the same feeling from your healthcare provider? I personally avoid the doctor as much as possible. I know how much I will get billed. Sometimes my wife thinks I’m crazy about how much against going to the doctor I am. But all those same feelings Dr. Makari uses to describe his experience at the car dealership apply to hospitals. You know are getting the short end of the stick.

But Dr. Makari isn’t a pessimist in all of this: he doesn’t just point out the problems. And he doesn’t just propose solutions that may not get implemented either. He highlights those who are trying to change things, who are challenging a status quo that is really difficult to break. Dr. Makari himself is involved in efforts to change current practices in healthcare. Dr. Makari has developed a program called “Choosing Wisely.” He has gone around to physicians and professional assocations to ask what they think are the top procedures that are overdone or unnecessary. You can check out the website for a few examples. He has taken it a step further by gathering data from doctors across America, so they could pinpoint which doctors are the ones who tend to over-use these procedures. He sends each doctor a personalized report, so they can see how they compare to their peers. And they self-correct. It doesn’t require any coercive measures or new legislation. These are grassroots measures that stem from physicians, which Dr. Makari believes work better. Internally derived corrections are more likely to see results.

But Dr. Makari doesn’t hold back any punches either. There are invested stakeholders in the system who don’t want things to change, and who lawyer up really quickly when they feel threatened:

I’m amused when I hear so-called health care experts blame one another for high prices. Nearly every one of these experts is beholden to one of health care’s big stakeholders and is afraid to speak critically about the entire system. Experts are afraid to upset their bosses, who may promote them to leadership someday, or they fear upsetting stakeholders, who may pay their speaking fees. But a critical view of the whole ecosystem is exactly what is needed.

In my opinion, Dr. Makari’s book falls well within Anand Giridharadas’s argument in Winners Take All: The Elite Charade of Changing the World that the win-win approach holds strongmen in the status quo free from responsibility:

There is no denying that today’s elites may be among the more socially concerned elites in history. But it is also, by the cold logic of numbers, among the more predatory in history. By refusing to risk its way of life, by rejecting the idea that the powerful might have to sacrifice for the common good, it clings to a set of social arrangements that allow it to monopolize progress and then give symbolic scraps to the forsaken– many of whom wouldn’t need the scraps if the society were working right.

Dr. Makari isn’t afraid to reveal “the man behind the curtain”, that the argument that “healthcare is complex, let’s leave it to experts” is no excuse, and that we should be doing something about it.

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