According to a doctor turned health care journalist.
By Julia Belluz for Vox. Above image: Smart Design/Shutterstock
“We hate our healthcare system. And yet we’ve come to accept it as an inevitable burden of being American,” Elisabeth Rosenthal writes in her new book, An American Sickness.
Rosenthal got a behind-the-scenes peek at the bamboozling when she was working full time as a doctor in the 1990s. She remembers one appendectomy patient, already in a hospital gown, pleading, “You guys [already] took my wallet … I don’t have a credit card.” The hospital was hassling the patient for a credit card number before continuing with the procedure, and the patient had to scramble to recover a card number from a friend before the operation could begin. It was clear to Rosenthal that profit came way ahead of patient care.
“That’s theater of the absurd,” says Rosenthal, the editor-in-chief of Kaiser Health News and a former New York Times writer.
But while anecdotes of the absurd, dysfunctional medical system abound these days, it can be difficult to know how best to navigate health care and avoid massive bills.
That’s where Rosenthal’s new book comes in: It’s a user’s guide to the American medical system. Rosenthal documents how health care evolved from a patient care system to a multitrillion-dollar business one perverse incentive at a time — and, importantly, what patients can do to fight back.
With health reform debates at a standstill in Washington, her advice for the millions of Americans stuck in the middle feels very timely. The conversation that follows has been edited for length and clarity.
You write, “We hate our healthcare system. And yet we’ve come to accept it as an inevitable burden of being American.” And the book felt very much to me like a wake-up call for patients.
It’s a difficult message to convey because there are lots of great people working within the system — doctors trying to do the right thing. But it’s not a system designed to encourage that. Then you see things like organized physicians groups trying to block price transparency laws or state laws that would require physicians to tell a patient if they’re out of network, [and] you wonder whose side these groups are on. What do they really care about? They always say [these measures] will create a burden or more bureaucracy — but really, how hard is to say to a patient, “Hey, I’m not in your insurance network”?
What do you think are the best ways patients can fight back against massive medical bills?
The system has gotten so bad because patients feel like helpless victims against this medical machine. You’re sick, and you don’t want to argue or piss off your doctor or hospital. But there are some things you can do. Maybe they won’t change the system but they will protect you in the short term from some of the more outrageous attempts to collect from you.
It’s important when you go into [a] hospital to insist and put on the 25 consent forms that you are willing to consent to the financial cost so long as providers are in network. People ask whether hospitals accept that. Maybe yes, maybe no, maybe you have to argue more — but it gives you a leg to stand on.
The other thing to know: There are a lot of errors on hospital bills. Get an itemization to see if what they say was done to you was really done to you.
You’re also an advocate for negotiating hospital bills, which I think is something many patients probably don’t realize they can do.
People don’t feel entitled to negotiate the way we would at a grocery store or furniture store — but we are put in a position where we have to, and if it’s going to save you thousands of dollars, it’s worth putting your notions about what’s an appropriate patient role in your pocket and getting a little more demanding.
So know that a lot of these bills are very negotiable. If you get a bill that says you owe $10,000, and you go in and say, “I’ll give you $5,000,” they may say okay.
The other tips you mention in the book — avoid a private a room, refuse unnecessary equipment, identify the people who come by your bedside and write down who they are or ask a family member to — are great ideas. But isn’t it absurd that sick people need to go to the hospital thinking about how to control the cost of their care instead of just getting medical help?
It’s a terrible burden to put on patients. You and I are health care journalists, and know the games and understand where pitfalls can be. But most people walk in innocently, and walk out feeling grateful for their care. They don’t want to alienate their physician. Then a few weeks later, they get a bill for $500, $1,000, $2,000 — and that can affect their credit rating. If they don’t pay it, that’s an incredible burden to put on patients.
In the book, you make it very clear that we got to this place because the values and techniques of the business world supplanted many of the values and techniques of medicine. Were there any particular profit-maximizing maneuvers in medical care that surprised you?
I was fascinated by that world of “physician extenders.” We have all experienced seeing the name of a doctor on your bill and thinking, “I never saw a doctor of that name.” And you realize part of the reason that happens is because you didn’t see that doctor. You saw a medical professional working under that doctor, but the doctor — because of years of lobbying by doctors groups — is now allowed to bill for that visit in his own name. There’s someone in the book who got bills both from the anesthesiologist and nurse anesthesiologist who weren’t present for the procedure.
In any other world, you’d think of that as kind of double billing. It’s not quite fraudulent, but it feels abusive. And yet it’s totally legal. Have you ever wished to be in two places at once? Doctors can be for the purposes of billing.
It doesn’t have to be this way. It’s not easy to change, but I think it can be changed.
At a more systemic level, what are the small changes you think we can make to move toward a more equitable health system?
I think one first place to look is greater price and information transparency. That won’t alone solve the problem, but it’s a crucial first step in any direction we choose. Patients and the doctors who treat them have to know what things cost, and hospitals and drugmakers have to be way more upfront about their charges.
Why are hospitals’ master price lists not generally open for public viewing? Doctors who practice in those hospitals tell me they can’t even see the chargemaster. Laws could change that. In some other countries, price lists and estimates are the norm.
This system progressively got built one action at a time, the perversion of one incentive at a time … in this endless inflationary spiral. There is the possibility to reel it back piece by piece. Looking for the grand solution, I fear, will prevent us from doing the small things we could to improve.
But I don’t think the distinction between radical reform and incrementalism is black and white. I do think there’s a way to get to single-payer incrementally. You just decrease the age for Medicare eligibility gradually until everyone is covered.
What other country’s health system are you jealous of?
There are a lot of choices we can make about how to deal with health care in this country. Some of them involve a more socialized or government-run system. Others rely more on market forces like the Swiss system. Some have a single payer. The thing you see when you look at around the world is that no one relies on a totally free market. You need a mechanism for controlling costs, whether it’s price corridors, ceilings, or negotiating national prices with the physicians, hospitals, and patient groups involved.
There are lots of different ways we can get to better, cheaper health care. What we are doing now with these policy debates is to keep choosing none of the above because we can’t agree on which direction we want to go in, and none of the above just keeps spiraling out of control.
I moved from medicine to journalism during the Clinton health plan because I thought there was going to be health reform happening then. I was working in the ER and doing freelance on the side but I thought, “I’ll go to the New York Times and write about health reform because it will happen, and then I’ll go back and be a doctor.” Of course, that never happened. Here we are talking about many of the same issues more than 20 years later.
I do think we’re reaching a tipping point, though. Putting aside whether we should be spending 20 percent of the GDP on health care, we are reaching a tipping point in terms of individual patients’ and families’ tolerance for the kind of cost burdens they are expected to pay.
What’s striking to me watching the discussion about health care here is how the rhetoric has become so divorced from reality. So much of the debate about health reform — talk about death spirals, reinsurance, the politics of Medicaid expansion — seems so removed from any discussion of actual patient care.
You hear these mantras repeated again and again that we have the best health care in the world. People accept this, but it has very little to do with the reality in the rest of the world often. The book was a wake-up call for me. I had repeated as a health journalist over and over that we’re innovating to get patient-centered, evidence-based care and that innovation can create patient-centered, evidence-based care. At some point, I took a step back and thought, “Wow, what other kind of medical care can there be?”