The Unhealthy Health-Care System, and How to Fix It

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Title: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back
Author: Elisabeth Rosenthal, MD
Publisher: Penguin Press
Publication Date: April 2017
Price: $27.95, hardcover; 416 pages

The United States spends considerably more on health care than all other wealthy industrialized nations. Yet, according to a 2017 report by the Commonwealth Fund, it ranks dead last compared with 10 other wealthy industrialized nations in most health-care metrics. Much has been written about the system’s problems and ways to fix them, but few publications have been as clear and well researched as the 2017 book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by Elisabeth Rosenthal, MD.

A Doctor-Journalist

Dr. Rosenthal holds her medical degree from Harvard, and she spent 22 years as a health correspondent for TheNew York Times. She lays the majority of blame for our bloated health system’s woes on greed: “In the past quarter century, the American medical system has stopped focusing on health or even science. Instead it attends more or less single-mindedly to its own profits.”

An American Sickness is a stellar book, but the author’s opening paragraph might lead readers to believe they’re in store for an opinionated polemic. Dr. Rosenthal certainly is passionate about her beliefs, but for the most part she backs them up with well-researched data.

Her book is organized in two sections. Part 1 offers the author’s view of the history of the current problems in the system, and part 2 details her “prescriptions for taking back our healthcare.” Some of the best chapters highlight compelling doctor-patient interactions, where Dr. Rosenthal’s medical background gives special insight. There are many disturbing tales of medical failures, which, as she points out, occurred despite the 2014 enactment of the Patient Protection and Affordable Care Act (ACA). She doesn’t spend much time on the ACA, noting, “it didn’t directly do much, if anything, to control runaway spending or unsavory business practices.”

Confusing Payment System

Billing for medical procedures is a wildly complicated process, complicated further by overbearing regulatory issues and mandatory reporting of data—ask any hard-working community oncologist. Therein lies one problem for readers, in that Dr. Rosenthal begins her book with a chapter called “The Age of Insurance.”

In the years after World War II, most workers received health coverage from their employer. The author discusses what was

An American Sickness is a dense book, and parts are too wonkish for the lay public. But it is a valuable addition to the ongoing debate about how to rein in untenable costs and derive more value from health-care services.

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colloquially called the “golden age of physician payments,” when insurer payment plans produced a significantly higher rate of growth, collecting 98% of the charges they billed through the “usual and customary” system that inflated prices. When Dr. Rosenthal moves into the purported fix for inflated prices—the resource-based relative-value scale—only policy-familiar readers will appreciate her efforts.

Some of the most valuable sections of part 1 are when the author tackles issues where real abuse to the system occurs, such as the regulation of medical devices. Here, her use of anecdotes and personal stories gives the narrative punch and rhythm. The U.S. Food and Drug Administration’s 501(k) process, which requires only minimal testing and oversight, is a fast track for device manufacturers to flood the market with expensive, and sometimes unnecessary, medical devices. Moreover, Dr. Rosenthal rightly points out that there is generally much less scrutiny of new devices than new drugs, even though most drug treatments can be halted if a problem arises, whereas many devices are permanently implanted. She drives home her message with a searing tale of joint replacement gone badly.

A Tough Fix

One flaw in the author’s diagnosis of the system’s ills is a lack of attention to preventable disease. (According to recent data from the Centers for Disease Control and Prevention, about 40% of the five leading causes of death are preventable.) Nor does she tackle America’s leading health crisis—obesity—which has overtaken tobacco as the leading cause of preventable death.

In part 2, Dr. Rosenthal attempts to diagnose and give a treatment pathway to “cure” our sick system, a much tougher task than elucidating the problems. Unfortunately, she leads with another sucker punch: “The American healthcare system is rigged against you. It’s a crapshoot and from day to day, no one knows if it will work well to address a particular ailment. Unless you’re part of the 1%, you’re only ever one unlucky step away from medical financial disaster.” Oddly, she fails here to address one of the system’s biggest opportunities for medical disaster: hospital-acquired infections.

Value-Added Suggestions

To her credit, Dr. Rosenthal gives insightful recommendations, such as giving pharmacists more prescribing power in certain areas, which will streamline the system and reduce costs. Another valid (but contentious) suggestion is to reform the patent process and revamp the drug and device approval system. The big suggestion—not new, but one that would save a huge amount of money—is allowing Medicare to negotiate drug prices with the pharmaceutical industry. The book also includes a top-notch addendum of tools for patients and a glossary, among other value-added content.

An American Sickness is a dense book, and parts are too wonkish for the lay public. But it is a valuable addition to the ongoing debate about how to rein in untenable costs and derive more value from health-care services. Dr. Rosenthal concludes her terrific book with this: “High-priced healthcare is America’s sickness, and we are all … being robbed. When the medical industry presents us with the false choice of your money or your life, it’s time for us all to take a stand for the latter.”

This book is highly recommended for readers of The ASCO Post