The Price We Pay by Marty Makari
The Big Idea: Hidden pricing, overtreatment, and entrenched middlemen have turned American health care into a predatory, wasteful system. Transparency, accountability, and value-based care can restore trust, lower costs, and put patients first.
INTRO
Most American hospitals were founded to care for the sick and injured regardless of race, creed, or ability to pay.
Health care leaders are generally not malicious.
Rising insurance costs are fueled by middlemen, kickbacks, and hidden costs.
Overtesting, overdiagnosing, and overtreatment are now common.
Transparency and competition can address many issues.
Health care is now an economic bubble.
Rising health care costs are burdening American businesses.
CHAPTER 1 – Health Fair
Doctors are performing unnecessary vascular procedures.
Stents offer no survival benefit for most patients.
No evidence supports screening for peripheral artery disease.
Heart stenting is declining, but leg procedures are rising.
Community health fairs often host predatory screenings.
Experts do not recommend certain vascular screenings.
Health screening can be a double-edged sword.
Doctors believe about 21% of all medical care is unnecessary.
Excessive medical care is a public health crisis.
Leg artery procedures can yield $100,000 in one day when doctors own the facility.
Doctors excel at subtly influencing patients.
Most appendicitis cases can be treated with antibiotics instead of surgery.
Doctors sometimes manipulate diagnoses to ensure insurance coverage.
Speaking the truth can bring professional backlash.
Doctors should take a stand on what is right.
Millennials have low tolerance for injustice.
Over 1,100 places of worship serve as vascular screening sites.
Many unwarranted screenings target people without symptoms.
Varicose veins are mostly cosmetic but are marketed as life-threatening.
Communities, often African American, are exploited by predatory screening.
Some churches have banned such screenings.
Improving Wisely is a collaborative to address medical appropriateness.
CMS plays a key role in regulating care.
Price gouging and predatory billing are widespread.
The cost crisis stems from inappropriate care and pricing failures.
Innovators are disrupting the system to lower costs.
CHAPTER 2 – Welcome to the Game
Patients sometimes consider surgery abroad for cost savings.
Hospitals can behave like used car lots in pricing.
Hospital charges are inflated and vary by insurer leverage.
The idea that hospitals must upcharge to cover charity care is unproven.
Hospitals inflate bills because insurers demand bigger discounts.
This cycle fuels rising insurance premiums.
Patients rarely know their costs upfront.
Hospitals conceal negotiated prices from cash payers.
True hospital costs are intentionally obscured.
Smaller surgical centers often offer lower, clearer prices.
Hospitals use chargemasters to inflate prices for profit margins.
Price gouging is a common business model.
Some patients are forced to pay full sticker prices.
The Amish often travel to Mexico for affordable care.
Uninsured patients with moderate incomes face inflated charges.
Debt collectors often violate laws and act ruthlessly.
Surprise bills arise from out-of-network services.
Surprise bills often come from behind-the-scenes specialists.
Networks now drive surprise billing and financial harm.
The law allows hospitals to charge any amount they choose.
Half of Stage 4 breast cancer patients face debt collection.
The billing “game” wastes vast resources.
Hospitals employ large administrative staffs for billing.
A “repricing industry” exists solely to negotiate bills after care.
Lobbying reinforces this expensive system.
The lack of real prices fuels predatory billing.
Sectors with transparent pricing have fewer predatory practices.
Price transparency could address root causes.
Most medical care is “shoppable.”
Hospital ratings should factor in price and billing quality.
Self-insured employers often prefer transparent facilities.
California protects hospitals that disclose prices.
Price transparency increases patient volume, revenue, and satisfaction.
Medical marketplaces like SesameCare are emerging.
The FTC’s Funeral Rule provides a transparency precedent.
CHAPTER 3 – Carlsbad
Investigating Carlsbad Medical Center’s billing practices.
A nurse was sued by the hospital that employed her.
Many Americans fear medical costs more than illness.
Carlsbad Medical Center is responsible for most lawsuits in its courthouse.
Inflated bills cause severe financial hardship.
Six in ten Americans have less than $1,000 in savings.
Deductibles may seem minor to the wealthy but are devastating to low-income families.
Hospitals sue patients, garnish wages, and damage credit.
Late billing can void insurance coverage for patients.
Doctors often dislike predatory billing once informed.
Communities can pressure hospitals to stop suing low-income patients.
Courts redact itemized bill details in lawsuits.
Community Health Systems owns Carlsbad Medical Center.
Media exposés can force hospital attention.
Corporate stock prices can collapse under public scrutiny.
National studies confirm widespread wage garnishment.
CHAPTER 4 – Two Americas
Doctors want to help, not ruin lives financially.
Community Health Systems owns hospitals that sue patients.
Mary Washington Hospital filed over 24,000 lawsuits in five years.
Most hospitals don’t sue patients, but nonprofits sue more than for-profits.
Many patients earn too much for Medicaid but too little to pay inflated bills.
Hospitals often mark up bills 2–23 times Medicare rates.
Suing patients brings negligible revenue but major harm.
Some hospitals increased CEO pay while suing patients.
Clinical and billing operations are often separate worlds.
The Restoring Medicine Project challenges predatory practices.
Hospitals drop cases when faced with expert witnesses.
Consent forms signed under duress should be invalid.
States should ban wage garnishment for medical debt.
Hospitals that sue low-income patients may not deserve tax-exempt status.
Half of women with Stage 4 breast cancer face medical debt harassment.
Powerful elites make the rules.
Even unaware hospital executives often condemn predatory lawsuits.
IRS once required nonprofit hospitals to provide charity care for tax exemption.
In 1969, the IRS loosened the requirement to “community benefit.”
In 2014, the IRS required clear financial assistance policies.
Hospitals must avoid aggressive collections without checking for aid eligibility.
Faith-based principles conflict with aggressive medical debt collection.
Some hospitals thrive on Medicare/Medicaid rates alone.
Transparent pricing protects patients from shocking bills.
Lean staffing and good pay can lower costs.
Hospitals can back low-interest loans to protect patients.
CHAPTER 5 – The Ride
Air ambulances have shifted from hospital-owned to investor-owned.
Patients face surprise bills for uncovered flights.
Private equity firms dominate the industry.
Multiple helicopters compete at accident scenes.
Bills can reach hundreds of thousands of dollars.
Out-of-network status triggers extreme price gouging.
Hospitals and air ambulance companies profit from urgency and fear.
Costs are passed to all through higher premiums.
Some companies aggressively expand by adding helipads and instant-call systems.
Rural patients suffer most from inflated air ambulance bills.
Sentinel Air Medical Alliance challenges these prices by revealing true costs.
Most flights are non-emergency transfers.
Only privately insured patients face extreme gouging.
Billing exploitation targets patients at their most vulnerable.
Industry giants sue disruptors to protect profits.
Three large companies control most of the market.
Medicare rates often cover actual costs.
Market oversaturation drives overuse.
Nonprofits tend to be safer operators.
High supply pushes companies to raise prices and push flights.
Prices are concealed from patients before flights.
Public outrage has pressured lawmakers to act.
Air ambulance profiteering mirrors broader medical exploitation.
Ground ambulances sometimes follow similar practices.
Patients increasingly turn to rideshare for emergency transport.
Doctors are speaking out against predatory billing.
CHAPTER 6 – Woman in Labor
C-sections carry risks like infection and longer recovery.
Doctors sometimes pressure patients with safety arguments.
Malpractice immunity may influence decisions.
Quality metrics focus on outcomes, not necessity of procedures.
One-third of knee replacements may be unnecessary.
A good outcome from an unnecessary surgery is still a problem.
Individual doctor patterns can reveal overuse.
Sharing performance data reduces unnecessary C-sections.
Some doctors’ Friday C-section rates spike dramatically.
Measuring appropriateness is complex and specialty-specific.
Patterns of overuse should be a quality metric.
The Choosing Wisely program raises awareness about overtreatment.
CHAPTER 7 – Dear Doctor
Mohs surgery payment structures can incentivize overuse.
The Improving Wisely model targets measurable overuse.
Doctors are compared to peers without penalties.
Outliers often change behavior when shown data.
Peer-designed programs gain physician support.
Over 80% of notified outliers improved.
The initiative created accountability and saved Medicare millions.
Civility is crucial for program success.
Metrics must be actionable, fair, and resistant to gaming.
Specialty-specific measures are more effective than generic ones.
CHAPTER 8 – Scaling Improvement
Some surgeons operate before trying cheaper alternatives like physical therapy.
A small group of doctors performs a disproportionate share of inappropriate surgeries.
Profit motives can distort treatment recommendations.
Access to current Medicare data transformed research.
Lack of randomized trials is not proof of ineffectiveness.
“No evidence” may mean untested, not disproven.
Lists of overused practices are growing.
Some procedures are overused because they pay well.
Splitting procedures into multiple visits increases revenue.
Doctor ownership of facilities boosts financial incentives.
Repairing is often better than replacing, but overuse persists.
Metrics can identify doctors using aggressive end-of-life treatments.
Underused low-cost alternatives threaten profitable treatments.
Many overused services are high-revenue procedures.
Hundreds of appropriateness metrics have been validated.
Consensus helps set thresholds for identifying outliers.
Metrics foster accountability and improve care.
CHAPTER 9 – Opioids like Candy
Opioids are the leading cause of death for Americans under 50.
Past training promoted generous opioid prescribing.
Pharma companies downplayed addiction risks.
Overprescribing is the root cause of the opioid crisis.
EHR defaults encouraged excessive quantities.
Most surgical patients do not need large opioid supplies.
Many prescribed pills are never taken.
Consensus guidelines can cut prescribing dramatically.
Publicly posting guidelines accelerates adoption.
Patients often prefer non-opioid options when offered.
The U.S. opioid crisis is unique globally.
Low pay discourages careful pain management.
Covering non-opioid pain meds could reduce overuse.
Nerve blocks can limit opioid need.
Changing EHR defaults can reset prescribing norms.
CHAPTER 10 – Overtreated Patients like Me
Lifestyle changes can reduce medication use.
Prescription volumes have doubled in a decade.
Over half of Americans take four or more medications.
Risks of treatment are often understated.
Statins work, but family history can guide decisions.
U.S. doctors are known for overtreatment internationally.
More prescriptions drive higher insurance premiums.
Physical therapy can replace some surgeries.
Unnecessary lab tests are routine before minor surgery.
Overtesting and overtreatment cause harm and waste.
Screening can trigger anxiety over harmless findings.
Doctors estimate 21% of care is unnecessary.
Overtreatment is a root cause of public health crises.
Overdiagnosis inflates disease rates without improving health.
Overuse is a global health issue.
Some cultures demand proof procedures were performed.
CHAPTER 11 – Starting from Scratch
Tesla’s customer-first model inspires health care reform.
Iora Health focuses on relationship-based care.
Patients receive extensive support from health coaches.
Coaches handle follow-ups, coordination, and social needs.
The system is paid a lump sum per patient annually.
Daily staff huddles align care teams.
Visits last longer and allow deeper connection.
Health coaches provide continuity and advocacy.
Understanding patient life circumstances reduces overtreatment.
Community-building combats loneliness as a health risk.
Hiring for empathy creates a strong culture.
Holistic teams improve job satisfaction and reduce burnout.
Medicare patients with complex needs benefit most.
Iora’s model has cut spending by 15%.
Other primary care groups replicate the model successfully.
CHAPTER 12 – Disruption
Out-of-network patients are treated like debtors.
Federal law requires emergency care regardless of payment.
Patients should remove harmful clauses from consent forms.
Hospitals cannot demand upfront payments from eligible aid recipients.
Deleting payment clauses can block collections.
Price transparency spurs competition.
Healthcare Bluebook shows fair market prices for procedures.
Cash incentives can motivate patients to choose lower-cost providers.
Price transparency laws in some states reveal actual payments, not just charges.
Chargemaster prices are fictional.
Transparency will not end all waste but can save billions.
American households want honest care at honest prices.
CHAPTER 13 – Buying Health Insurance
Traditional brokers earn commissions that incentivize higher costs.
Self-insuring can save employers money.
Catastrophic insurance covers extreme costs.
Some brokers reject commissions and charge flat fees.
Kickbacks are common in insurance and PBM contracts.
Flat-fee brokers align incentives with clients.
Health Rosetta certifies transparent brokers.
Employers can demand full commission disclosure.
Health co-ops offer alternatives without broker kickbacks.
CHAPTER 14 – Pharmacy Hieroglyphics
PBMs act as powerful middlemen in drug pricing.
Spread pricing hides massive markups.
Copays can be arbitrary.
PBM contracts gag pharmacists from revealing true costs.
Most Americans get meds through PBMs.
Rebates are hidden kickbacks.
PBMs often own the pharmacies they reimburse.
Mail-order programs can create unwanted medication stockpiles.
PBMs and insurers are often co-owned.
Three PBMs control 85% of the market.
Some states ban spread pricing in Medicaid.
Consumers can save by shopping outside insurance.
Online discounts like GoodRx can beat insurance prices.
Employers can demand transparent PBM contracts.
CHAPTER 15 – 4K Screens
Group purchasing organizations (GPOs) control hospital supply chains.
GPOs demand pay-to-play fees from manufacturers.
Exclusive contracts reduce competition and risk shortages.
Clinicians are often excluded from purchasing decisions.
Safe harbor laws allow kickbacks in GPO contracts.
Kickback costs are passed to patients and taxpayers.
Hospitals can bypass GPOs for better deals.
Direct purchasing could be disrupted by large retailers like Amazon.
Repealing safe harbor exemptions could restore competition.
CHAPTER 16 – Diagnosis: Overwellnessed
The workplace wellness industry is a $6 billion business.
Wellness programs often promote pseudoscience.
Screening healthy people can cause harm.
Some wellness companies sell collected health data.
Diet advice often relies on outdated, incorrect theories.
Sugar, not fat, is the greater dietary threat.
Some genetic testing companies sell data to pharma.
Biometric screenings can contradict medical guidelines.
Wellness ROI claims are often false.
The “Safeway Amendment” incentivized employee health surveillance.
True cost drivers are entrenched medical stakeholders.
Selling employee health data has become a revenue stream.
Few wellness programs deliver real results.
Quizzify educates employees about overtreatment.
Some employer wellness offerings still add value.
The Validation Institute certifies programs that work.
CHAPTER 17 – The Words We Use
Medical training prioritizes memorization over care coordination.
Business of medicine is largely absent from medical education.
Doctors lack training in teamwork and behavioral skills.
Much of medical knowledge becomes outdated or irrelevant.
Medical schools reinforce hierarchy and rigidity.
Some schools now teach humility, compassion, and communication.
The profession should use honest, patient-centered language.
“Costs” should be called “prices.”
“Preventable adverse event” should be called “medical care gone wrong.”
“Charge-to-cost ratio” should be called “markup.”
“Financial aid” on inflated bills is “predatory lending.”
Employers, not insurers, ultimately pay for care.
Taxpayers, not Medicare, fund government coverage.
Self-insurance can offer better value for employers.
CHAPTER 18 – What We Can Do
Insurance companies pass gouging costs to consumers.
Grassroots movements push for fair billing and transparency.
Corporate America spends more on health care than core materials.
Medical pioneers often refused profit for public good.
All health care stakeholders must reduce waste.
Transparency and honesty can rebuild trust.
Patients should always ask for prices in advance.
Basic patient rights should include timely quotes.
Projects like Choosing Wisely and Improving Wisely promote appropriate care.
Hospitals should be ranked partly on billing practices.
Most Americans demand price transparency.
The American Hospital Association has opposed new transparency rules.
Covid accelerated telemedicine and value-based care models.
Direct contracting between employers and hospitals is growing.
Environmental causes are gaining focus in cancer research.
Businesses can save millions through transparent benefits design.
Never pay the first bill without review.
Adding billing quality to hospital ratings is underway.
Millennials want to be part of meaningful reform.