There was a time in America when people trusted their doctors, and the mission of hospitals was to care for the sick with compassion and charity. Today, one in five Americans is in collection because of medical debt.
Of course, there still are good doctors and reputable hospitals, but the fundamentals of the US health-care system are broken.
An undeniable fact: We pay more for our health care than any other country in the world. In exchange, we get overtested, overdiagnosed, overtreated…and overcharged. What broke the American health-care system, and is there any way to fix it?
For solutions and advice on not becoming a victim, Bottom Line Health spoke with Marty Makary, MD, MPH, a leading authority on spiraling health-care costs and unnecessary medical treatment.
A secret and predatory gold rush
When it comes to out-of-control health-care costs, there is plenty of blame to go around. The culprits include insurance companies, hospitals, pharmaceutical giants and a few “bad apple” doctors. Predatory pricing and inappropriate care are the main drivers of our broken system.
A shocking example: A standard heart bypass surgery costs about $15,000 in France. In the US, a heart bypass, with an equal quality of care, could range from $40,000 to nearly $500,000, based on a recent survey of 101 heart surgery centers.
Hospitals inflate their bills because insurance companies pay only part of the sticker price, and hospitals agree to keep that insurance-covered sticker price secret. A patient who doesn’t have insurance or goes out of network often is charged the full sticker price.
And even if you have insurance, you can get crushed by a surprise bill. This happens to about 60% of Americans. Surprise bills include uncovered lab work…facility charges…and charges from doctors you never see, such as those who read your pathology report and your imaging study. They may be outside your network, but nobody tells you until you get the bill. These bills add up and are part of the reason why almost half of all women with stage 4 breast cancer are being harassed by medical bill collectors.
Big Pharma plays a significant role, too. When insulin was discovered, the researchers sold the patent for just $1. They felt that it was unethical to profit from a lifesaving drug. Today, pharmaceutical companies that produce insulin have engaged in price fixing, jacking up the price so much that one out of four patients with diabetes reports that they ration their insulin.
About 20% of medical services provided in the US are unnecessary, according to a survey conducted by researchers at The Johns Hopkins University. That includes prescriptions, medical tests, procedures and more. Among the most common examples…
Leg stents. Narrowing of the artery that supplies the leg muscles is common as people grow older and sometimes leads to painful peripheral artery disease (PAD). A simple screening test can find the narrowing.
Studies show that many of these patients do not require surgery to remove plaque and open the narrowing with a balloon or stent, but these procedures have become a cash cow for some doctors.
Spine surgery. Half of elective spine surgeries for back pain are unnecessary. Surgery could cost up to $100,000. What’s the best clue that spinal surgery is unnecessary? If it is recommended before you try physical therapy.
Appendectomies. More than 300,000 appendectomies are performed in the US each year. But studies show that an early case of appendicitis can be treated with antibiotics. This will be effective for approximately 75% of patients without the added risk of surgery.
How to protect yourself
The key to changing the health-care system is transparency. Imagine this: What if you were booking a flight and the airline couldn’t tell you how much it would cost until you land? You could be charged anything the airline wanted.
That’s what is happening with health care, but it does not have to be that way. In fact, most medical-care costs are predictable and subject to comparison shopping. Here’s my advice to protect yourself…
Demand upfront pricing for your medical care. Remember the heart bypass example earlier? Before scheduling the surgery, you can get upfront pricing by calling your health insurer to ask how much is typically paid for the procedure in your area. Then ask what is the maximum amount you can be charged out of pocket. Don’t be afraid to talk directly to the hospital or the practice’s finance office and show them the fair market price (see below).
Note: In the vast majority of cases, quality of care is not linked to pricing. In fact, many of the top medical centers in the US accept Medicare coverage, which is almost always an extremely competitive rate for medical services.
Get an itemized bill if you think you have been overcharged. Review the itemized version carefully to make sure you aren’t paying for outright errors such as $370 for a tube of toothpaste and razor that should have cost $37 and/or fees that exceed the market rate for your area.
The following free websites can help you negotiate a lower upfront price or contest a bill that exceeds market rate for a medical service…
FairHealthConsumer.org helps you find a fair price for various medical and dental procedures for your location based on a database of more than 29 billion private health-care claims for services paid by private insurance plans.
GoodRX.com tracks prescription drug prices and offers drug coupons for use at locations throughout the US and online. In some cases, the discounted price actually is lower than the cost of the drug when it is covered by insurance. A mobile app is also available.
HealthCareBlueBook.com provides the reasonable amount calculated from a nationwide database that you should pay for numerous medical procedures and services for your location.
RestoringMedicine.org gives consumers 20 tips on negotiating excessive medical bills with strategies including contacting local and national media outlets, paying in cash and filing a complaint with the state attorney general.
Also helpful: If you run into problems getting a price or fighting a bill, consider asking your doctor for help. In most cases, your doctor will be as shocked as you are.
Some doctors will call the hospital administrator on the patient’s behalf to question the bill. You also might contact a member of the hospital board. These people, who usually live in your community, may be willing to intervene by questioning the hospital administration about billing practices.
Beware: While hospitals are obligated to treat you even if you cannot pay, out-of-network hospital care can mean an up to 500% markup.
To avoid this trap, pay close attention to the form the hospital makes you sign before treatment. Part of it is a consent for treatment, but there also will be a clause that says you will pay 100% of whatever the hospital charges. You can cross this part out…and you should. Doing so will not affect the quality of care you receive.