How can doctors cure America’s ‘sickness’?

In her new book, "An American Sickness: How Healthcare Became Big Business and How You Can Take it Back,” Elisabeth Rosenthal, MD, takes a clinical approach to examining the current state of healthcare and the proper treatment plan to fix its ills.

To analyze the complex challenges facing healthcare today, Rosenthal traces the evolution of the problems with the healthcare system-from insurance to hospitals to the rising prices of pharmaceuticals-while also offering some solutions.

Elisabeth Rosenthal, MD

Rosenthal recently spoke with Medical Economics to discuss the book, including how physicians shaped the chapters and can enact change going forward.

 Medical Economics: Discuss your interactions with physicians for the book. What is their level of frustration with the American health system?

Hot topic: Hospitalists, PCPs bad communication hurts patient care

Elisabeth Rosenthal: Important to [physicians] was feeling a loss of control over the values of medicine they thought were really important to them in deciding to become a physician. They are frustrated with the time spent on the bureaucracy of medicine versus time with patients, which is why people went into medicine instead of other professions that would have paid well. The feeling like, in the past, you could do the right thing for your patient, but now it’s much harder-that’s the frustration.

Another common theme I heard again and again was they did not control pricing and had no way to control it. So their patients come back and say, “Hey doc, thanks for taking out my appendix, but I got a $40,000 hospital bill I can’t afford.”

Any caring physician feels really bad about that and they get the brunt of that frustration, and it doesn’t make you feel good that you helped someone and then bankrupted them. That wasn’t their intention in becoming a doctor.

So I think there was a sense that we were paying out a lot of money in our system for things that really didn’t involve medical care [in the hospital bill outside of the cost of the actual surgery], which they saw-and I see-as the real focus of “value.” That’s what medicine should be about: the care.

More: Everything doctors need to know about asking patients about sexual orientation and gender identity

 ME: And a lot of what physicians are doing is uncompensated, such as checking online for the best prescription drug prices.

ER: Neither patients nor physicians asked to be put in this “consumer-y” healthcare world, where I, as a patient, have to shop around for a knee replacement. I didn’t ask for that, I just need my knee replaced. And physicians are in a similar situation. They have to send patients for an MRI. They often have no idea what their hospital will charge for that MRI and they have no control over it, and it’s only after [the procedure] they find out the cost because the patient complains about the bill. The doctor hates that. 

Likewise with prescription drugs. It didn’t make it into the book, but this dermatologist prescribed an acne cream for a kid and the mother came back after going to the pharmacy and asked if he knew it would be $300. Doctors are caught off guard by prices all the time and it is frustrating for them. They have plenty else to do than calling around.

I hope doctors can band together to demand [access to] those prices. It shouldn’t be an exercise in being a detective. They should know it. And that’s why I’m somewhat ambivalent about all these pricing sites both physicians and patients are going to. Yes, they provide useful information, but the bottom line is that knowing prices shouldn’t require detective work; this should be out there.

Trending: CMS should exempt all, not just some, small practices from MACRA

 ME: Speaking of banding together, do you think doctors do enough of this to advocate for change in healthcare?

ER: Doctors don’t do enough and it would be impactful if they did more. On the other hand, physicians are busy people who have another job, so realistically, it is hard. They didn’t go into medicine to become lobbyists. That’s not what they want to do, but I do think just as knowing about prices was not something they ever wanted to have in their wheelhouse, if we want to change the system, it would be great if they were more active.

There are a couple of stories in the book [about physicians] who have taken it upon themselves to try and push back to seek leadership roles in their hospital, their communities or in local medical groups, and not through the specialty societies or the American Medical Association (AMA).

I think the first ones out there [will] put themselves at considerable professional risk in that hospitals and insurers will see them as troublemakers. Someone joked to me after he started a campaign for more price transparency, he thought he’d drive to his hospital and find his parking spot taken away. And others mentioned more serious repercussions. 

I remember in medical school, the big question for doctors was, “To whom is duty owed?” The answer, of course, is the patient. But it’s different if you are working for a big hospital system that says, “You have to do an MRI before you examine every knee, you have to order an occupational therapy consult on every patient who is discharged, etc.”

Popular online: How to decipher direct-to-consumer genetic testing

You ask, as a physician, particularly if you are a physician working for a big conglomerate health system that works very much like a business: Who is your allegiance toward? Is it my patient or my hospital/employer who can terminate me at will? The values of big hospital systems now are business values and not healthcare values, and that leaves doctors vulnerable if they disagree with the corporate culture.

 ME: This is also the case at smaller, independent practices, isn’t it?

ER: The challenge I hear from many is that they are trying to work within a [healthcare] system they are uncomfortable with, and yet still feel good about what they are doing and get joy from it. It’s having that gratification of medicine not suffocated by the practical aspects of practicing today, which involves your payer negotiations, your hospital affiliations, your various professional certification requirements.

In the book, I followed around an independent cardiologist who I knew when I was a resident, just to see what it was like. It was miserable. Just the amount of time he spent getting prior authorizations, checking on insurance, etc.; He eventually shut down his practice and I think that’s sad. He’s the kind of doctor I would go to. He’s the kind of physician we say we value the most-and yet they are the most at risk. 

I think, as patients, we need to be more vocal, too, and say we value thoughtful care, especially primary care. It is incumbent on both physicians and patients … everyone has grumbled in private on both sides, but not been active. We need patients to say this is not OK. That this is what we want from our medical care and we want these guys valued and able to access the information they need. We want to know about price, but want it easier for our physicians to have this information and not working at midnight to find it.

It’s a bit of a David and Goliath effort. Hospitals have consolidated. Insurers have consolidated. Doctors are never going to be as consolidated, so maybe the answer is for a different kind of doctor to get involved in the AMA to recognize and drive common patient-physician interests. 

 ME: The “Age of Physicians” chapter highlights physicians gaming the system (via Medicare fraud, for example). Where do you think the majority of U.S. physicians fall? Are they trying to exploit loopholes in a troubled system or playing by the rules given to them?

ER: Most doctors in their motivation are totally in the “good side” category and not bad apples. But there is a huge grey area to me. 

I think many physicians have done things that are ambiguous in terms of value for cost: Are they good [for patients] or are they money-making opportunities? But the big question is: Have they resorted to these money-making opportunities because it is just so hard to get paid for what they actually do? I think the whole system has encouraged, and in some cases necessitated, doctors to look for profitable activities in order to make things sustainable. 

Further reading: Where precision medicine is headed

At some level, the impulse is also natural. You say, “I’m referring all these people out for physical therapy and this physical therapy center run by a business person is billing $500 an hour for a PT session. That’s nuts. Why should I send my patients out? I can do it better here, so why shouldn’t I get that money?” I understand that, particularly when you feel you are not being paid well or at all for some of the important services you do give patients.

It is very complicated. You see in that chapter on physicians who are offering things for a lot of money that are not useful, but they are being called out by other doctors in their community for doing those things.

I remember hearing from one cardiologist in New Jersey who somewhat reluctantly sold his practice to a hospital and said he felt like he had two choices: “[Sell to the hospital], which I’m OK with, while I liked being independent. The other was to do what the guy down the street is doing-everyone who walks in the door gets an echocardiogram and a [stress test]. I didn’t feel good about that-I knew every patient didn’t need that.”

 ME: You identify many culprits for the current state of healthcare in the U.S. today, from hospitals to insurance companies to pharma. Is one more to blame than the others?

ER: One thing I came to believe in writing the book is that it is the interplay of the different parts that is the most important factor. That doesn’t mean that things like pharmaceutical prices and device prices shouldn’t have better kinds of price controls, but I wouldn’t say they are the bad guy. I think we need to address each sector where we can.

For hospitals, most are nonprofits, but they run with “operating surpluses.” And they spend that money on things that maybe their community wouldn’t say are benefitting patient care or the community. I lived overseas for 10 years. To say a U.S. hospital looks like a Hilton would be an understatement. Perhaps it is more like a Four Seasons. In most of the world, hospitals look more like junior high schools. They are not fancy places.

This is where patients come in. Americans fall for this stuff. They say, “I love that hospital, it has beautiful art and free coffee.” So we allow our healthcare dollars-and encourage hospitals-to fund those things rather than more community clinics or knowing infection rates to see if this is the hospital we want to go to.

Hot topic: Do younger doctors outperform older physicians? 

 ME: Now the $3 trillion question: How do we fix healthcare in this country? What is a true, actionable start to solve all the ills you outline in the book?

ER: It is hard. And it doesn’t mean just saying “single payer” and we are all fine. That doesn’t mean single payer won’t work here and couldn’t be gotten to in a gradualist way. You could get there by saying, as Hillary Clinton said, we are just going to lower the Medicare age every couple of years. Thirty years from now, or at some point, everyone would wake up and say, “We have single payer”-what happened?”

Medicare does a decent job in controlling prices and keeping overhead low. Yes, it has its problems, but more and more patients and physicians I hear from are telling me things like, “I’m so sick of this system, I could live with [single payer].”