Book Review: An American Sickness by Elizabeth Rosenthal, M.D.

June 5, 2017 / By Norbert Goldfield, MD

“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.” So begins Dr. Elizabeth Rosenthal’s just published book, “An American Sickness: How Healthcare Became Big Business and How You Can Take it Back.”[1] The book’s stories are devastating as she recounts what is wrong with our healthcare system and what we can do to fix it. I recommend the book and buy her fixes, but only to a point.

At the book’s outset, we find Rosenthal’s ten “commandments,”[2]  or as she calls them, the “economic rules of the dysfunctional medical market”:

  1. More treatment is always better. Default to the most expensive option.
  2. A lifetime of treatment is preferable to a cure.
  3. Amenities and marketing matter more than good care.
  4. As technologies age, prices can rise rather than fall.
  5. There is no free choice. Patients are stuck. And they’re stuck buying American.
  6. More competitors vying for business doesn’t mean better prices; it can drive up prices up, not down.
  7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
  8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
  9. There are no standards for billing. There’s money to be made in billing for anything and everything.
  10. Prices will rise to whatever the market will bear.

The first two-thirds of the book describe painful, dispiriting, often heartbreaking incidents (many all too familiar to those of us “in the business”) that highlight each of these ten commandments. Stories like the Vitamin D lab test billed at $772, “an ice pack that vibrated” for $10,000, or the non-profit, “patient-centered” Cystic Fibrosis Foundation that gained royalties from a new treatment for the disease, priced at $300,000 per year and developed with funding from venture capitalists[3]—the stories go on and on.

As a physician who mostly still sees low-income patients, I like to remind myself (and all healthcare professionals who reads this blog) about the Hippocratic Oath from the first physician, Hippocrates: “To teach them this art without fee or indenture; I will use treatment to help the sick. I will abstain from all intentional wrong-doing and harm, and whatsoever I shall see or hear I will never divulge.” In other words, to take this oath means acknowledging that treatment should be either free or affordable, professionals should gladly help the sick, maintain confidentiality, and most famously, first do no harm.

Dr. Rosenthal focuses the last third of her book on “prescriptions for taking back our health care.” The first part of her proposed solution discusses what I would call patient activation, engagement or confidence. A number of pioneering researchers in the field of patient empowerment, notably Judy Hibbard, Kate Lorig and John Wasson, have concluded that continuity and confidence are key factors in successful patient engagement. I know this first hand from my own practice, as exemplified in the following vignette:

Around 8:30 PM one Sunday night, the personal care attendant for one of my longstanding diabetic patients called me. I let it roll into voice mail and then listened to the message. The patient’s blood sugar level was 530 (normal is up to 100). I called the patient back, spoke with her for about one minute, made a clinical assessment that the situation could be managed at home (instead of a trip to the emergency room), and texted her twice over the remainder of the evening (taking up about 30 seconds) to check on how she was doing. Over the next two hours, the patient’s blood sugar level gradually decreased to 220 and the next morning it was at 116. I’ve known my diabetic patient for 25 years. She felt comfortable contacting me. She had the confidence to know that something was wrong.

Dr. Rosenthal provides an excellent list of questions that individuals should ask as part of any medical visit. These include: “Will you refer me only to other physicians in my insurance network, or explain in advance if you can’t?” or “How will this test/surgery/exam change my treatment?” These are the type of questions that a confident, activated and empowered patient should ask. In fact, it would be helpful if Dr. Rosenthal offered a Cliff Notes version of the questions to help educate and encourage individuals in being activated when it comes to their care. 

Is confidence enough? It might be enough when buying a car, but even with cars the government has a significant role in pulling cars off the road. There are publicly and privately sponsored tests that specify the repair record (i.e. outcomes) for cars. Therein lies the challenge in Dr Rosenthal’s book. She claims that it is “big business” that has ruined health care. Yet, fifty years ago, dialysis and bypass grafts and many of the new medications that lengthen people’s lives did not exist. Inventors developed antibiotics and insulin a mere 100 years ago. Health care became a business because…medicine requires labor and machinery in order to advance. Business was absolutely needed to develop the machinery that led to the dramatic advances in medicine over the past 50 years.

Hospitals, not just the manufacturers of dialysis machines, are businesses within the healthcare economy. They must be business-like in how they manage the labor and machinery needed to “operate” a hospital. Determining how we should pay business for this machinery and how we should pay for the labor that goes into operating the machinery are topics at the heart of this blog. As many of you know, I advocate paying businesses for better outcomes.  

At the end of the day, health care is like the car industry. It’s a critical part of our national economy, yet Dr. Rosenthal does not systematically answer the challenge of how the public and private sector should engage with the healthcare economy. In fairness, Dr Rosenthal highlights other important actions that need to happen. With respect to the cost of pharmaceuticals, for example, she writes about the approach the Europeans have taken which is very much a pay for better outcomes approach.

I suggest that the challenge that confronts us as healthcare policymakers/ researchers is that we haven’t been able to craft relatively simple messages for politicians to promote. We need politicians of all stripes to work together to craft a public-private partnership that will improve the quality and decrease the cost of our healthcare economy. (Joseph Antos et al provided us with one such approach in a recent JAMA article[4]). As I advocated in a recent blog, politicians should shout “Let us pay for better outcomes quality!” With deference to Dr Rosenthal, health care is an economy and should be judged on its effectiveness. Let’s address this health care economy with a public/private partnership as so many of us have advocated and at the same time, encourage patient empowerment as you so eloquently promote in your new book.

Norbert Goldfield, MD, is medical director for 3M Clinical and Economic Research.

[1] Rosenthal, Elizabeth; An American Sickness: How Healthcare Became Big Business and How You Can Take it Back.

[2] Ibid, page 8

[3] Ibid, page 187

[4] Antos, Joseph; Capretta, James; Wilensky, Gail. Replacing the Affordable Care Act and Other Suggested Reforms JAMA. 2016;315(13):1324-1325. doi:10.1001/jama.2015.19499