The Sinking of the USS Healthcare
From the doctor’s desk:
Like a big beautiful cruise ship, U.S. Healthcare, offers a wide-ranging experience—from the open-air suites up top to the fourth-class cabins below. And, like the cruise lines, we in Medicine are not without our gaffes and scandals. Something feels off. Is U.S. Healthcare heading for danger? Or have we already hit the iceberg and failed to notice? Just ask the soggy folk at the bottom of our medical ship. They’ll tell you.
I’ll start with an example of the smallest of leaks. A friend sent me a message with an attached medical report and a short, sweet “Whaddya think?”
I read the EMG/NCV results with interest. For those who don’t know, an EMG/NCV is a relatively unpleasant medical exam that probes the workings of the nerves in our arms and legs. It involves needles and electricity, served up with a side order of “The Inquisition.” The words on the page droned on about “mild neuropathic changes in the median nerve” and a “moderate chronic L5 radiculopathy.” Basically, doctor blah-blah-blah that describes a person who’s been walking upright on a spinning planet for six decades. That wasn’t what caught my eye. But the part about my friend’s “normal ears, lungs, heart sounds, and soft abdomen” sure did.
So I asked my friend, “Did the doctor, whose singular job was to administer this test and nothing more, look in your ears?”
“No.”
“Did he pull out a stethoscope and listen to your heart and lungs?”
“Nope.”
“Touch your belly?”
“Uh, no.”
“Well, his note—the basis of his bill—says he touched the crap out of you.”
“Hmm. He did hook me up with all sorts of pins and pads before zapping the shit out of me. Does that count?”
“Yes,” I said, “it counts, and it’ll keep on counting until your bill is paid.”
I’m sure the doctor’s bill reflected the test performed, but in addition, it almost certainly included a bill for a fabricated physical exam. What happened here? As a physician, I could talk about pre-templated notes, “relative value units,” CPT and ICD codes, etc., but I’ll boil this down to its essential oil: intentionally or not, this doctor committed fraud.
Maybe this was an errant click of the mouse. But here’s the hard truth. So many doctors’ bills contain “mistakes” it’s hard to find the line between oversights and avarice.
Shocking! Or is it? Turker’s Law (not a real law) states: when a medical practice or behavior, ranging from disagreeable to heinous, is—over decades—tolerated, then incentivized, and eventually benchmarked, it loses its stigma and produces an exhausted physician’s shrug.
Here’s another anecdotal fact—which thirty years in Medicine tell me is pretty accurate: 95% of our healthcare providers simply want to care for their patients and don’t want to bankrupt them. But times have changed since the days of doctoring in return for eggs and chickens.
Almost one-fifth (18%) of the U.S. economy, the big number—our GDP, goes to the “healthcare industry.” By that measure, it sounds like a very productive sector. In reality, we’re hemorrhaging healthcare dollars through an overly-complex system that pits doctors’ incentives against their patients’ best interests.
It’s impossible to say where all our health dollars go, the system has so many leaks. In the early 2000s, a for-profit medical company, HCA (Hospital Corporation of America), was fined hundreds of millions for fraudulent billing. Paid with the corporate equivalent of a shrug, it stood as anything but a cautionary tale. Then came the innovative Electronic Medical Record (EMR), the father of the “imaginary physical exam.” We’ve even monetized our dying relatives. According to the New York Times, three-quarters of hospice care is now for-profit. Hospice care!
And, per Becker’s Hospital Review, thirty-five billionaires (billion with a “B”) made their fortunes in U.S. healthcare—most of them in pharmaceuticals, medical devices, and EMRs. Fortunes made off the misfortunes of others.
So many hands reach out and grab their due. For example, we have Pharmacy Benefits Managers, a mostly unregulated industry that “negotiates drug prices.” But for whose benefit? We employ 180 thousand billing specialists. Some fight for the insurers, others for the doctors, but no one fights for the little guy who’s paying the bill. And health insurance companies send us confusing but reassuring letters stating, “This is not a bill.” Often a prelude to a collections company phone call.
We talk about “highly productive doctors” who see more patients per day and do more cases per week than their colleagues, but what’s our product? What do I, as a surgeon, produce? Most of us are paid for what we do to people, not what we do for them. In the words of an old surgeon friend, “We’re cuttin’ people, not makin’ bagels!” He was kinda crude, and kinda right.
Doctors train for a decade to learn to work as a team, keep people healthy, or at least make them comfortable. Sounds great—until we graduate, and then we’re told, “You gotta edge out the competition” and “dominate the market!” That “competition” is our former teammate, and that “market” is a collective group of our grandparents, kids, and spouses.
All of us, doctors included, will one day fall ill or just plain fall, and we’re as likely to be gouged by our own healthcare “industry” as anyone else. The rising cost of care delivery is one thing, but being charged for care not delivered is an outrage.
For now, the uninsured and underinsured bear the brunt of this cost, but nothing stops the rising tide. It’s a simple lifeboat psychology: between those in the boat and those in the water. Hearing the cries of the uninsured in the water, the insured stay quiet and follow the captain’s orders to pay their increasing deductibles and co-pays. Even if, one day, the rising cost of care will tip them over as well.
It’s an oft-heard fact. The U.S. spends about twice as much on healthcare as any other Westernized country, yet we rank 44th in life expectancy. One step behind Estonia. (All due respect to the Estonians. Clearly, they’re doing something right.) What is also clear is that we are doing something wrong. We clung to our employer-supplied health insurance model, cobbled together in the aftermath of WWII—a hodgepodge system of haves and have-nots. While European countries pooled their resources to rebuild their economies and build universal healthcare systems from the keel up, we kept patching our leaky boat.
For decades, the upper decks of U.S. Healthcare have looked innovative and sleek, but below the waterline, we have a problem. Look at the staggering bills flooding your mailbox. What would happen if we, as a society, were to do something crazy, and instead of building another fancy but unstable amusement park of the sea, we built an unpretentious yet seaworthy vessel for all? One kept afloat by our pooled tax dollars and not artificially inflated bills.
The downside? We’d have to retrain some of our health-adjacent partners to perform different jobs. The upside? Maybe something more rewarding. And for the small number of “cruise line owners” who might lose their title as one of thirty-five U.S. healthcare billionaires, perhaps there are better ways to amass nine-figure portfolios than through our inevitable illness and injury. I heard there’s a ton of money in sneakers. (I know, sounds crazy when I say it out loud.)