There was incredible push back from dermatologists on the story about Mohs surgery [a procedure that involves slicing off a skin cancer in layers under local anesthesia]. The American Academy of Dermatology sent a long letter to the editor and letters to their members. They told them not to talk to the press and refer all questions to their trade association. But I also got letters from dermatologists at the NIH and in academic centers saying, “I want you to know you are right.” So that was very heartening. There are many highly committed doctors in this system who are as frustrated by the pricing as patients.
How would you characterize the pushback from the medical establishment in general?
Probably a lot less than I would have expected. There’s been an awful lot of silence. The hospitals and doctors know they are in the cross hairs now. Everyone knows or feels change is coming. They are nervous about it and hoping it won’t be big change. And as I said, there are plenty of doctors who are unhappy about the profiteering, too.
How did patients react?
At first patients say, “I have this great doctor; he has coffee in the waiting room.” They look at their own micro-experience. They focus on the things they can understand. But often people don’t know if they got good care. It’s hard to know. When people have something done, they tend to assume it’s life-saving. It will take a population approach to sort this out. Are you getting good medical care, or too much care—high-end care that makes no difference for your health? What I do know is when they open their ever-rising medical bills and face ever-rising premiums, they are shocked and feeling the economic pain. They want to know why it costs so much. And they are frustrated and outraged that no candidate has made this an issue.
What needs to be done?
There needs to be a change in the incentives whether it’s a move to more marketplace intervention—a real market—or a single payer, national health system. I would like people to know what the options are, and once they understand the origin of our high-priced system encourage a more open discussion of what kind of system they want to have. But this is not an issue people get to vote on. Very few people are happy with the system they have. The question now is, how do you translate a snowballing sense of outrage in the community to political action?
How do you see your job in the context of changing the system?
My job is to start a very loud conversation that’s difficult politically to ignore. The medical associations, the doctor groups have spent a lot of money to lobby. There’s nothing that’s equivalent on the patient side to reflect how patients feel.
There have been a number of steps groups have taken to attempt a conversation. What are your thoughts on those?
There are some easy first steps like making hospitals publish a Chargemaster, a list of its retail prices [which almost no one pays]. But it is not a final answer. Transparency only gets you so far. If all a hospital had to do is say what they charge for gallbladder surgery, patients still have to figure out what the surgeon and the anesthesiologist and the radiologist will bill. Those are all separate bills in our system. And you need a better way to judge how the hospital compares to others in terms of patient management.
What would be more powerful and effective to bring about change?
Why can’t politicians take on a more adversarial position with the health industry? Take the medical device makers who want to repeal a tax on their products that was mandated by the ACA. Look at members who have supported the repeal—Elizabeth Warren and Al Franken—I assume in part because they come from states where device makers are powerful. They didn’t stand on principle. Healthcare money has infiltrated the system. That’s not good for patients. The real yardstick is does the system do a good job for patients, but that’s not the metric we use.
What is the metric we use?
Well, that’s the problem. We have no metric and no agency that’s really looking at the big picture for patients. Think about it: The FDA just judges drugs safe and effective. The patent office certifies that they’re novel and so deserve a patent. But no one says, is this really better than what’s already available in terms of patient health, and should drug makers be able to charge four times more than in any other country here in the US? I’ve heard from countless doctors who are frustrated that their patients—even those with insurance—can’t afford the medicine they prescribe.