The Price We Pay: What Broke American Health Care--and How to Fix It by Marty Makary

The Price We Pay: What Broke American Health Care--and How to Fix It Reviews

• 
  Janet Newport

  This should be required reading for ALL adults. Should be read at least annually by all employed int the "health care industry."
  
  According to the US Bureau of Labor Statistics, employment in the "health care industry" is projected to grow by 14% over the next 10 years. Their reasoning is based on our "aging population" fueling demand.
  
  Several months ago, I called my insurance company to ask a question. The little gal sort of answered it... mostly I didn't understand. It concerned a "facility fee" charge for a fully covered X-ray. While I explained to her that it was done in the same building that housed my doctor's office, I just didn't understand. NO Facility in Birmingham, Alabama keeps their X-ray equipment out in a field somewhere without electricity, she said I still had to pay the silly $ 74.00 bill. Then she went on to tell me that my policy would pay in full if I were to get a mammogram. NO! NO! NO! Just NO!
  I do not ever want another mammogram. I had one once and I swore never again. Well Okay then,
  your insurance plan will cover in full the cost of a colonoscopy. Same answer as before but louder. Than I hung up before she could inform me of other "benefits" my plan covered.
  
  There is no history of either breast or colon cancer in my family. While I'm likely to die of something..... (absolutely guaranteed to die), it will likely be something else.
  
  This was an easy read, yet horrifying indictment of our current medical system. While I received this book from the library, I am also ordering from Amazon to keep as a future reference guide.
• 
  Kirk

  In The Price We Pay, Marty Makary, an accomplished surgeon at what is considered to be one of the founding institutions of modern American medicine, bears witness to the clusterfuck that is American health care practice.
  
  Bearing witness is the psychological practice of acknowledging that something exists or is true and the corresponding act of sharing ones individual experience about that truth. In his non-partisan (thank God) deconstruction of the abysmal American system, which neither functions on a free market nor in accordance with adequate policy safeguards, Marty graciously acknowledges time and again that he himself was ignorant of the realities of the broken system, despite operating within the belly of the beast. It's his entrenched position and professional credibility, however, that allow him to network thoroughly and gather such critical insight into the system as a whole. What is more, it's his strength of character, coupled with his commitment to the Hippocratic Oath, that motivate him to report back to the general public so as to motivate change, and thereby prevent further financial, emotional, and physical harm which are the current dividends of a system focused on inappropriate care.
  
  The book is told in three parts. The following are descriptions and summaries of the contents:
  
  Part 1 - Gold Rush (Bad actors operate legally within the system with impunity.)
  
  1. Predatory health screenings which commonly target elderly, high-risk, and rural populations encourage unnecessary medical treatment. They are short on actual information and long on financial incentives to recruit new customers.
  
  2. Makary summarizes the bad economics of American health care, to wit: price-gouging, insurance networks as analogous to
  protection rackets, lack of price transparency, and the creation of a repricing industry.
  
  3. Inquiry into Carlsbad Medical Center and it's medical billing as akin to predatory lending. The hospital charges unreasonable prices, and then uses civil court to strong-arm patients into paying by way of garnished wages and ruined credit.
  
  4. Further inquiry into predatory billing in other hospitals. Makary learns that non-profits are as culpable as for-profits at predatory billing, despite their tax exempt status. “The interest and court fees amounted to 60% of the principal. That sounds less like a hospital that’s there to serve and more like a payday lender that’s trying to hound a patient in debt. Those aren’t quite loan shark interest rates, but if you’re asking ‘What would Jesus do?’, I’m pretty sure this ain’t it.”
  
  5. Makary analyzes the air ambulance industry to show how runaway costs function within one sector of health care.
  
  Part 2 - Improving Wisely (Pattern analysis and fostering competitiveness between surgeons can improve treatment outcomes.)
  
  6. Makary discusses how the philosophical underpinnings of traditional health care quality assessments must be reconsidered. In our current assessment of "appropriate care", we consider complication rates, re-hospitalization rates, process reports, etc., but we don't focus on whether the procedure was appropriate in the first place or lifestyle factors for the patient in the first place. Makary proposes a new metric called "Improving Wisely".
  
  7. A case study of "Improving Wisely" as it pertains to Mohs surgery. Peer bench-marking and realignment of incentives resulted in millions of direct savings to Medicare.
  
  8. Makary applies the underpinnings of the previous two chapters to other types of care such as breast surgery, cardiac surgery, gastroenterology, etc.
  
  9. Interpreting the opioid crisis by understanding the application of practice patterns.
  
  10. Makary argues that over-treatment is as bad, if not worse, than under-treatment. The opioid crisis, antibiotic resistance, increasing health care costs, thyroid cancer surgeries, and other issues all result from over-treatment. “For years, health care reform in Washington D.C., has asked one question: How do we pay for health care? But the real question is: How do we fix the health care system? Addressing the epidemic of too much medical care (which doctors believe represents 21% of all medical care delivered) is a practical solution. My own medical experiences have reminded me that the problem is not just administrative waste, it’s clinical waste as well that’s driving up the health care costs for everyone.”
  
  Part 3 - Redesigning Health Care (Makary analyzes less well-known reasons why health care costs are increasing, from Pharmacy Benefit Managers to quasi-ethical Wellness Programs at work.)
  
  11. The author introduces several companies who are focused on re-designing health care using a relationship-based model of care: Iora Health, ChenMed, and Oak Street Health.
  
  12. Price transparency is a necessary prerequisite to any health care reform, particularly considering price transparency yields quality transparency.
  
  13. Health care brokerage (an industry notorious for trade secrets, predatory retention, and misaligned sales incentives) is a flaw analogous the the brokerage of CDOs which resulted in the financial crisis of 2007. Makary proposes self-insuring as well as finding "Rosetta certified" brokers as a solution.
  
  14. Many people don't know that Pharmacy Benefit Managers exists, and they exist as yet another racket within health care. The goal of a PBM is to increase the spread, or the difference in amount between what they pay a pharmacy and what they invoice a health plan for medication. The PBM keeps any rebates the drug manufacturers or pharmacists offer, and many times the PBMs are owned by the health insurance company they work for (thus increasing the profit margin). “The PBMs have gone to great lengths to keep real prices secret, using a fog of fees, rebates, and discounts that make a true value too complicated for anyone to determine. Even if an employer figured out the spread on a few medications, there are thousands of these meds and they go by different names, have different comparables, different generics, different schedules, and different dosages - and each combination of these variables is priced differently.”
  
  15. Makary summarizes the chapter himself: “The conflicts of interest inherent in the modern GPO (Group Purchasing Organization) business model continue to limit innovation, drive up prices, and cause unacceptable shortages for the most basic drugs and medical supplies.” Group Purchasing Organizations are the middlemen who purchase hospital supplies, and those GPOs may not even be in the same state as the hospital for whom they are acting.
  
  16. Wellness committees are invasive, quasi-ethical, and have no scientific credibility with respect to commonplace health metrics. The employment of wellness committees nationwide can be attributed to pseudoscience, governmental support, and the illusion of employee benefits.
  
  17. Medical schools should evolve to teach more holistic and care-centered medicine as opposed to rote memorization. Our public discourse about health care should match the perceived realities instead of distancing us from the issue.
  
  Like any expose on American health care, Makary's book is frustrating. It's frustrating because powerful forces have designed an unwinnable game that Americans are obligated to play. He concludes his book with a call to action, both for those within the medical field and without, though he has a special call for those within medicine considering they are to do no harm, therefore it is their ethical responsibility to change the system. Though the system is broken, Makary does a good job including reasons to be optimistic in every chapter. He regularly cites specific doctors and clinics that are doing their best to provide quality care focused on a different, more appropriate understanding of what "care" means. I had no issue with Makary's quality of writing, and the book moved quickly and was full of excellent passages to note. The lack of politics within this book cannot be understated or over-appreciated.
  
  I'll borrow from The Wire and conclude with the following: "We used to heal people in this country. Now we just put our hand in the next guy's pocket."
• 
  Donald Powell

  A book everyone should read. The author tells all about healthcare in the United States of America. The language is common and the logic is common sense. He reveals it all in great detail. He is bringing conscience and morality into the discussion about healthcare, its policies, its financing and its games.
  
  This book is a short, concise and critically important revelation of a major arena everyone will encounter. It is absolutely shameful that this book is not mentioned in every news story, talk show and political event in the country. The money at stake is probably the only reason it is not.
  
  PLEASE READ THIS BOOK!
• 
  Donald Crane

  I almost quit reading this book after the first two or three chapters. Makary's style of writing seemed rather imprecise to me, and having read numerous articles by Atul Gawande, another physician-author who writes impeccably - I was turned off by Makary. (Despite exemplary credentials, as an accomplished surgeon and assiduous researcher at Johns Hopkins University.) It seemed like he levels blanket charges against aspects of the health care system without identifying that there is a range of practices - some good and some unconscionable - among hospitals, physicians, middlemen, pharmacy benefit managers, and pharmaceutical companies. (Well, maybe not PBMs and pharmaceutical companies!)
  
  As I got past my dissatisfaction with style, however, I began to see that he had correctly diagnosed the major issues in the health care finance system that result in frequent inappropriate and unnecessary care as well as prices that are often predatory, especially as applied to those who can least afford it.
  
  He addresses examples of:
  
  - hospitals suing patients for collection and garnishing their wages
  - unnecessary cesarean sections primarily for the convenience of the obstetrician
  - lack of transparency in pricing and inability to get an estimated price prior to having a procedure
  - wildly variable and absurdly high pricing for identical helicopter transfers
  - excessive prescription of opioids (at one point, looking in the mirror at his former approach to prescribing 30 days' supply following surgery)
  - out-of-network price gouging, resulting in surprise billing and balance billing that are subject to Congressional scrutiny at the moment
  - opaque pricing models by pharmacy benefit managers (PBMs) that result in unjustifiable prices charged for medication)
  - lack of transparency in the way medical professionals communicate with patients (using medical jargon when straightforward and simpler language would improve understanding)
  
  Makary's recommendations is that we all take charge of our own health, question physicians or hospitals when they suggest a procedure, and demand a price estimate prior to undergoing a procedure. Speaking directly to me as a hospital trustee, he also suggested that trustees make sure they understand how the institution's pricing model works, how the hospital's charity care program is constructed, and how unpaid bills are handled (in terms of collection activities).
  
  To me, the one thing that patients can do that didn't receive sufficient attention is to engage in healthy lifestyles that reduce the need for the healthcare system in the first place. We all know what is needed: eating healthy, unprocessed foods; getting regular exercise and adequate sleep; managing stress; avoiding smoking; and managing the use of substances that can be destructive if overused (alcohol, drugs).
  
  I was glad I stuck with the book, notwithstanding my misgivings in the beginning.
• 
  Alexis

  This was a frustrating read. The data was good; the analysis and conclusions, not so much.
  
  The good parts: The data and stories about how much we pay, the inaccessible chargemasters, the opaque billing, CEOs who don't know their ass from their elbow and claim ignorance of how their hospitals operate. Dr. Makary does a great job of showing many of the ways in which the system fails.
  
  The bad: Trying to analyze the situation and draw political conclusions. Makary is a fan of price transparency. I'm not opposed to that, per se, but he doesn't address the myriad limitations to the problem. Once your care costs enough, it is immaterial to you whether it's $30K or $50K; you've hit your maximum. Second, you don't always have the ability to do research, either because it's urgent or because the patient is generally incapable. The issue of pushing the burden onto patients isn't really addressed. Third, lack of competition. One of the highlighted stories is in Carlsbad, NM, where the local hospital has a record of suing for unpaid bills. The next nearest hospital is in Roswell, an hour away. That's usable for some people some of the time, but for other people and times, Carlsbad's hospital has a captive market. With increased consolidation in healthcare, transparency will be only so useful as a tool.
  
  He's also a little overly generous about the motivations of doctors and administrators, which is interesting considering his opening story about predatory surgeons promoting unnecessary surgery. Doctors respond to incentives, both good and bad.
  
  To his credit one segment is about improvement at the hospital level, by using data to improve surgical outcomes. However, in some cases he's prone to tossing off anecdotes. For example, that providing price data for deliveries meant "everyone" selected the cheaper hospital, with "no loss of quality." It's worth noting that the example was in Boston, where Partners Healthcare has been accused of driving costs up at the most prestigious hospitals. I know from personal and friends' experience that even when price data is available, that the more expensive option may be chosen because of real or perceived differences in quality or other factors. (For example, I chose to deliver in a more distant hospital because I preferred its maternal-fetal medicine team, and would have done so even if it had cost more.)
  
  He also talks up companies self-insuring and the use of health shares without mentioning downsides (self insured companies are exempt from the requirements of the Affordable Care Act; health shares do not guarantee payment).
  
  It's a shame because the basic data gathered is really interesting; he just doesn't know where to go with it.
• 
  Julie H

  Everyone should read this book! The American health care system is broken and this book does a great job of explaining it.
• 
  Austin Lords

  In this book, Marty Makary takes the reader on a quick tour of the broken American health care system. The main culprits in his mind are excess/unnecessary care, administrative bureaucracy (e.g. insurance companies, insurance brokers, hospital supplies, billing departments, etc.), and general complexity and lack of transparency stemming from such a complicated system with so many stakeholders.
  
  It is quite obvious that many of these issues are pet-projects for Dr. Makary as he has done great work by creating advocacy groups and spreading awareness around some of these issues. However, I believe he has provided very little justification that his arguments are the true drivers of health care costs at large. For example not once did Dr. Makary mention the outrageous cost of medical school & malpractice insurance. Nor did he mention America's strong patent laws on prescription drugs, the doctor shortage (b/c med school is so hard to pass!), or doctor salaries. Only in passing did Dr. Makary mention differences between the American system and other advanced economies.
  
  Dr. Makary does a fair job at pointing out legitimate problems in the health care system. His position can be summarized as the following: get rid of the middleman, increase transparency, deliver the right care at the right time. That's it. Overall the book is very approachable and enjoyable to read. Dr. Makary uses a lot of examples and personal stories to drive the narrative, which I found helpful. I did learn a lot and I think he has a valuable message. But if you are looking for a book that will dive into the complexities of the American health care system and politics you won't find it here. This book is about trimming the fat on the existing system from a health care professional's point of view. It does nothing to question the fundamentals of American health care (e.g. employer-sponsored health insurance).
• 
  Susan

  A really powerful book and a searing exposé on the healthcare industry in America. I knew that the healthcare industry wasn’t great, but I didn’t know it was this bad. There are some horrifying stories and jaw-droppers. The lack of transparency, price gouging, middlemen, secret kickbacks and the overall business model of the healthcare industry are really depressing and infuriating.
  
  This book contains very important information and ways the healthcare industry could improve — and what we as individuals can do. I really respect the author’s passion. As a surgeon, Dr Makary is doing so much to improve the system.
  
  Be warned, however, that this book is not for when you want to have a good mood.
• 
  Justin

  ***I was granted an ARC of this via Netgalley from the publisher.***
  
  The Price We Pay: What Broke American Health Care – And How To Fix It by Marty Makary, looks at the reasons why healthcare costs for Americans are out of control and the ways in which people are working to change the way we fundamentally structure healthcare and focus more on the patient than profits. In this book, he looks at many areas where patients are being price gouged and taken advantage of. This includes the high cost and in transparency of the cost of care in hospitals, doctors doing unnecessary procedures and the way the compensation for insurance brokers, pharmacy benefit mangers and group purchasing organizations does not benefit the people they provide service to but themselves. But while pointing out the failings in America's healthcare system, Makary also points to examples of positive changes that the healthcare community should take note of and strive to emulate. Through a mix of personal stories from his own experience as a doctor, Americans struggling to pay their medical bills and people in the industry trying to improve how we conduct medical care, Makary reveals the inner workings of a system many find bewildering and hostile and shows us ways it can change for the better.
  
  Read my full review here:
  
  https://openlettersreview.com/posts/t...
  
  Rating: 5 stars. Would highly recommend to a friend.
• 
  Mike Cheng

  Agree with the conclusion (i.e., that healthcare in America, as far as costs go, needs fixing) and even some of the premises (e.g., one major problem is the lack of transparency in pricing, another is the gap between provider and consumer), but somewhat disagree with how author and MD Marty Makary gets the reader there. Most of the book uses emotional appeals in the form of anecdotal hard-luck stories to lambast / shame various hospitals, pharmas, or other providers for charging or trying to collect on admittedly egregious bills. In my humble and uninformed opinion, this misses the mark by focusing too much on a symptom and not the root causes (though they are briefly addressed). Still, the last chapter does provide some very limited advices about certain actions the average person can take.
• 
  Mason Rodriguez

  This book by Dr. Makary presents incredible insight into the predatory and nonsensical buisness performed everyday in the world of healthcare. It is alarming to me that Marty and his team alone were able to uncover the myriad problems displayed in the book and I hope that this book will spur more research into the problems run rampant in healthcare. I really enjoyed this book and will have to give it another read very soon. I highly reccomend this book to anyone interested in why our healthcare system is so terrible, especially if you are a current or aspiring medical professional.
• 
  Larry

  A wonderful book by Marty Makary of John Hopkins. Many descriptions--and even better explanations--about the different parts of of health care system with more than a few recommendations on how to improve the parts that don't function so well. It even includes an explanation of how helicopter/ambulances have been misused as a money making opportunity. But its focus is really on the basics ... like why some hospitals routinely overcharge patients and then take them to court while others operate much more ethically. And it has one of the best explanations I've seen of why the price for medicines is so hard to figure out. He even explains why mail order is rarely your best option. Finally Makary explains why the doctors we have in our system have virtually no training in how to work together and with other medical staff.
  
  In reading this book, you will be very frustrated as Makary reveals all the problems ... but you will also be hopeful as he gives examples of hospitals, doctors, and other parts of our health system have figured out better ways to deliver a better product to patients.
• 
  Siyu

  It’s not terribly well written but very informative (and infuriating). Worth listening to it! I find myself wondering why he has not once proposed that we look at how other, socialist countries manage their healthcare - a big believer in markets
• 
  Obada Kattih

  Imagine you are going to get an oil change for your car. You ask an employee how much it will cost, and they tell you they can only tell you after they've completed the service. When you get your oil change, you get a bill for $10,000, and if you don't pay you will get sued, collections will come after you, your credit score will get hit, and some money will be taken out of every pay check until the bill is paid. That is the current american healthcare system as it stands in much of the country.
  
  This book should be a must read for every adult american. It can literally save you thousands of dollars. Dr. Makary really dives deep into the issues of american healthcare, and he uncovers a lot of appalling facts about the system. Like many things in life, healthcare is extraordinarily complicated. However, the system as it is now is unsustainable, and at the end of the day the people who are paying the most are the american taxpayers.
  
  In this book, he discusses our for-profit healthcare system, unethical medical practices, price gouging, price transparency and the lack thereof, insurance companies and brokers, pharmaceutical companies, unethical legislature that enforces the status quo, measures that can be taken to change the system, alternatives to the system, and much more.
  
  Rarely have I learned so much and been so shocked by a book before. The business aspect of medicine is a topic I knew very little about, but after reading this book I feel much more well-versed in the field despite the shock of what I learned. This book makes me much more passionate about being part of the solution to the american healthcare crisis that we are all paying the price for.
  
  If you've ever wondered why american healthcare is so much more expensive than that of other developed nations, or why your insurance premiums seem to go up every year, or if you're dealing with a healthcare issue yourself, or if you're simply curious about how the healthcare system in america works, this book is a must-read.
• 
  Soleil

  A timely follow-up to Rosenthal’s American Sickness and other books that examine the U.S. health care system at a macro level. Marty provides an on the grounds look at lesser-known drivers of health care spend: insurance brokers, PBMs, GPOs. He criticizes various hospital practices, including surprise billing and wage garnishing, which contradict the “do no harm” mantra of medicine. He admonishes the outsiders: the air ambulance companies and private equity firms that have infected health care and seek to profit as out-of-network enterprises. He even critiques medical education on the whole, urging educators to focus less on the rote memorizing and more on what truly matters to patients. I found myself nodding along, though occasionally wondering how certain findings (e.g., outlier doctors get paid more for performing more reexcisions) could be so bewildering to his clinical audiences.
  
  Unfortunately Marty’s viewpoint as an academic physician, at times, feels constrained. He is strangely unwilling to discuss Medicare for All or any broader health reforms that entail a public payer - one that could restrain price gouging, limit surprise medical bills, and cut middlemen as he so desires. Hell, why not cut reimbursement rates across the board? Instead, Marty’s proposed reforms (e.g., changing insurance broker compensation to flat fees, require spread transparency for PBMs) are small-scale and mild, suggesting that he is reluctant to fully butt heads with his medical colleagues and community for the sake of his cause. This is the biggest downside to this book and what differentiates Makary from Rosenthal. The latter is former MD who, no longer tied to medicine, works freely as an opinionated journalist and writes like one too.
• 
  Karen

  This book needs to be required reading for every American!
• 
  Elena Susan

  every doctor, politician, health care worker, student, employer, & parent - every AMERICAN - should read this book. as someone who knew next to nothing about health care or insurance or hospital fees, i didn’t expect to enjoy this book, and yet i could not put it down. dr. makary’s writing style is easy to read, approachable, honest, relatable, and funny, all while explaining complex concepts and processes in a confusing system. and he even offers practical advice for what individual people like you and i can do to combat the twisters, expensive american health care system. i feel like i am finally starting to understand a world that was previously shrouded in mystery, and i feel empowered to do something to help the honest, vulnerable people who are attacked by american health care every day. perhaps what i found most refreshing was dr. makary’s honesty and humility; though a doctor himself, he never hesitated to point out ways his own industry and practice needs reform. he never points the finger of blame at other people for the sake of saving face, but rather discusses practical forms with honesty for the sake of helping individual people gain quality healthcare and financia stability. and he doesn’t just point out the problems and leave his readers hopeless, but he offers inspiration and advice from around the globe to encourage us and spur us onward to change for the better. if you feel frustrated by the american health care system: you’re not alone. this book is a chance to expose its cracks and begins to work toward reform. dr. makary’s ideas are changing the nation and i feel honored he wants us to be a part of it.
• 
  Scott Holstad

  An absolute must read for a country where the majority of bankruptcies are from excessive medical bills. We're fed crap about fearing and loathing "socialized" medicine, which is basically what virtually every other first world civilized country has to one degree or another (and the US quietly has a bit of its own, but the politicians don't want us to know that). So we've been brainwashed and trained to hate commies and socialists and everything except free market capitalism. Except free market capitalism is failing the vast majority of Americans so quickly, badly and permanently, the concept of a middle class will soon exist only in history books. I certainly think little of Marx and his ilk. I think that's been more than proven as a failure. I've spent my whole life hearing about the evils of "socialist medicine" like you'll find in Canada. Why is it so evil? Cause you'll have long wait times, they'll raise your taxes, you won't have options, the healthcare will be inferior.
  
  Okay, my response. Long wait times? Longer than the US? I waited 13 goddamn months to see a neurologist I was referred to and because I have so many neurological problems, he (like most doctors I see) declared himself overwhelmed, he had to spend time reviewing my medical history, and to make an appointment for 12 months later. My wife and I were aghast, because I have serious disorders and I desperately needed a couple of minor brain surgeries and had been largely incapacitated waiting months and months to see him with the expectation these would be set up. Nope. Another example. This involves both time and competence. In 2016, I developed severe stomach and abdominal problems, so much so that if I touched any food, the nausea and pain were indescribable and crippling. Considering I already had what is viewed as the most painful disease "known to mankind," commonly called "the suicide disease," that's saying a lot. So I made an appointment with a GI, had to wait forever, had the usual tests which showed nothing so he dumped me. I demanded more tests. Just because the first one didn't show anything didn't mean my symptoms went away, yet that's how 80% of my doctors acted. One test, find nothing, goodbye. Assholes! To shorten it, it took 2 and a 1.2 YEARS of me going from specialist to specialist, undergoing over 30 tests, being sent to some of the best hospitals around the country while I starved, losing over 175 lbs in less than two years. If I ate anything, I puked and suffered for hours. My wife kept me alive with a few bites of baby food every few days. Finally, after all of the doctors had given up, I started doing my own extensive research, and then testing and experimenting on myself -- not for the first or third time -- and ultimately determined the cause, so I wrote up a 20-page paper with data, resources, results, etc., met with several specialists, and turned out I was right. I had a pancreatic disease, which those morons never considered testing. No options? What options do we have here? I have to take the insurance I can get. I have little practical choice over deductible, because if I want to choose something actually affordable, the damn premium is not at all! And historically, many haven't covered most pre-existing conditions, some dump you if you come down with too many problems, most of the time you still have insane expenses, and meds? ONE of my essential generic pancreatic medications costs more in one month than I make. So I can't afford it and have gone back to suffering. Meanwhile, some of my doctors have encouraged me to get some meds from Canadian pharmacies, so while one of my meds isn't even covered by my insurance here but I could pay retail of something like $600 for a third of a month, I can get three months of the same thing from a Canadian pharmacy for less than $125! Yeah, socialized medicine is freaking evil! Anti-American. You know why it's considered anti-American? Because the bozos brainwashing us over the past decades are all making a KILLING off the US healthcare and pharmaceutical industries and they'll use any propaganda, any manipulation to keep the system the way it is, even though it's killing and breaking us. Higher taxes? Less than going bankrupt because we can't afford higher damn medical costs! You think about that. Again, we've been so brainwashed into believing taxes are evil - despite the fact that no government can run without them - that we don't want to pay any, even if it hurts us. Which it is. I don't have all day, so I'll end before I want to with one final example. When I was young, my father worked in Canada for several years. We moved there from New England, and later moved back to the mid-Atlantic region. While there, I contracted a very serious disease that, back in those days, could be terminal. I was placed in a special hospital, completely quarantined, and given regular, personal treatment and attention 24/7/365. My parents lived hundreds of miles away and I got to see them on my birthday. I was there for a year and a half. In America, my parents would have been so broke, so destitute for life, so devoid of hope even though I survived, simply due to the I'm sure MILLIONS of dollars in medical bills that incurred. Many resort to suicide. But you know how much my parents were forced to pay for all of that? NOTHING! Not one damn cent! And THAT is the evil of socialized medicine while I have been seriously ill here in the US for over a dozen years, have spent millions and lost nearly everything I have paying fucking CO-PAYS, when if I were still in Canada, I wouldn't have spent crap. Oh the evils the other countries face...
  
  We're damn idiots! This book doesn't go quite where I went, but I wanted to emphasize its importance to all of us, and supplement it with some of my own tales. I advise everyone to read it. The system is more than broken here. It's time for a massive fix. Recommended!
• 
  Sonali

  2.5 stars
  
  this book gives a solid high level overview of all the components of the healthcare system from an expert in the field, and there were so many relevant and heartbreaking first hand accounts of ways the system is failing communities across the board
  
  but those are pretty much the only positives. in an attempt to make this accessible or more like a novel, the author uses really random transitions that offer nothing to his overall message and got really annoying. about halfway through, he stops relying on scientific evidence and seems to really rely on anecdotal evidence from his own experience to make his points. and while there were micro solutions offered or shared, there was no systematic solution or commentary based on all his research, aside from 2 sentences dismissing ACA.
  
  decent overview, but not the comprehensive and unbiased read i was hoping for.
• 
  Elspeth

  I think the topics in the book are extremely important and everybody should read this to get a better understanding of the costs in healthcare and ways for physicians to use data/peer comparison in practice improvements. I did feel the content was repetitive in places and the many many similar stories should have been cut down.
• 
  Scott Wozniak

  This is a hard book to read, but not because it's written poorly. Quite the contrary, it's written so well it feels like a page-turning suspense story. No, it's hard because when you see how broken the healthcare system is in the US it will hurt and likely make you angry.
  
  Let me be very clear, do not confuse the quality of medical care and the healthcare system. American doctors are world class and we continue to be world leaders in developing new procedures and medicines. Our medical personnel are amazing.
  
  What's broken is the overall system of assigning people to "networks," determining price, collecting payment, etc. I really cannot exaggerate how unfair it is in some places while how right next door there is a facility making noble, fair choices.
  
  A few examples:
  
  Some private companies show up at car accident sites, approach injured people and say that helicopter would be safer method than an ambulance ("every minute matters"), only to end up sitting for 3 hours in the hospital waiting room and then being charged for $63,000 for that flight--oh, and they don't tell you the cost of the flight until a month later when they send you the bill.
  
  The great majority of pharmacies get their drugs through a PBM organization. Most PBM's have a line in their contract that restricts pharmacists from telling you what price they are getting the drugs for and from telling you whether there is a generic brand that's cheaper. Some pharmacists tell you anyway, but it's literally illegal for these medical professionals to give you the full truth. Oh, and it turns out the same pill is sold for $40 in one place and $271 across the street. (That's why they aren't allowed to talk to you about this.)
  
  It turns out there is a big spike in c-section births on Friday afternoons. This isn't because babies like to be born on Friday. It's because there is a percentage of clinics who incentivize their doctors to avoid weekend births to reduce overtime.
  
  I could go on and on and on.
  
  But the best part of this book is that unlike many who rant and point out problem, he offers real solutions. From public policies to new business models, this book gives me hope that changes are being made--and fires me up to make even more changes.
  
  Powerful read. Highly recommended. Whether or not you work in the healthcare space (my company consults to them) it's still valuable because we all use these services.
• 
  Janae Johnson

  This was an excellent book—a must read for everyone!! I fully expected it to be reading a book about politics and healthcare reform, but instead got a book about (wait for it) HEALTHCARE! I learned so much and am left both horrified and hopeful. There is so much change that can happen, even before it gets to the legislative level. I really appreciated the emphasis on the need for transparency in pricing and how healthcare can and should operate like other businesses while being a place of healing and real charity for anyone who needs it (without killing them financially later). This book did not have a partisan bias, just a rally cry for all Americans. The author had a very casual and conversational tone which might turn off some, but I found it very easy to read, especially having no experience in a healthcare profession. I felt like I was in a class with a fun professor who truly loves what he teaches and has a sincere desire for change.
• 
  Geneve

  "For years, health care reform in Washington D.C. has asked the question: How do we pay for health care? But the real question is: How do we fix the health care system?"
  
  This book blew my mind and left me with my jaw hanging open and my blood boiling multiple times after reading about the way the American health care system, from health care providers to hospitals to insurance companies, wreaks havoc on patients' lives. No part of the broken health care system is left untouched. As a nurse, things such as unnecessary tests, overprescription, and the flawed way that reimbursement is determined based on quantity rather than quality are no surprise to me. But the business aspect of healthcare was particularly eye-opening, which Makary does not shy away from addressing. He shines a light on the middlemen of health care - pharmacy benefit managers overcharging employers and pocketing the change for their employees' medications and insurance consultants who are paid bonuses for getting their businesses to renew their insurance plan that may not actually be saving the company money in the long run - that I never knew about before. But the best part of the book was that Makary just didn't leave it all gloom and doom, but highlights individuals and health care companies trying to change the status quo from the ground up. It gives me hope that we all, together, can ensure that every American receives quality health care, not necessarily because we find better ways to fund it, but because we find better ways to fix it to be more efficient, equitable, and accessible. Highly, highly recommend for anyone, but especially for my fellow healthcare colleagues to be reminded that although we operate in a broken system, we should keep striving and innovating to do the best for our patients.
• 
  Dhanya

  This book is incredibly approachable and Makary’s calls to fix healthcare are pretty simple: watch for middlemen (insurance brokers, pbm��s, billing departments) and increase transparency/limit predatory practices (no price gouging and wage garnishing). He also provides many solutions for how we can negate this at the individual level.
  
  Makary is an admirable professional who delves into necessary advocacy and a multitude of side projects; however, I would have liked for him in this book to delve into some more fundamental issues in medicine (that are really at the root of these greedy conventions), such as: whether employers should sponsor health insurance, how physicians respond to incentives, and the costs associated with malpractice insurance/medical school. Perhaps this is the downside of a book heavily based on anecdotes, but the anecdotes were super helpful in breaking down jargon and making healthcare concepts very approachable!!
• 
  Carolyn Burns

  This should be required reading for every member of Congress.
• 
  Hayley Hu

  The book reminds me of why I like reading books. All the facts in the book and the author's deep investigation are so new to me but I have been the victim of the system for so long.
• 
  Marks54

  This is an outstanding book about health care. It is one of the two or three best popular accounts of what are extremely complicated and pressing health care problems that are available anywhere. The author is a surgeon at Johns Hopkins who runs a center looking at the appropriateness of health care across a variety of specialities. By appropriate is meant health care that serves the public and provides high value to patients and society.
  
  What does that mean? It generally concerns a strongly patient centered and transparent approach to medicine. It - or its absence (inappropriate care) means a lot of things, most of which are tied to the excessive prices in health care, the skyrocketing premia even for those with insurance, the poor health outcomes that large number of Americans put up with, and huge and irregular drug prices that most everyone suffers under, and the scandalous treatment accorded by US healthcare providers to those at the lower end of the economic class scale. This is not a book about democrats versus republicans or Trump versus Obama. The issues raised in the book have been around for a long time and are likely to continue into the future.
  
  What makes this book so special? Because the author is a surgeon (and knows a lot of doctors, nurses, and other professionals) he start the study of appropriateness in medical care by looking at what a baseline for appropriate care would be. To help in this effort, he is one of the first researchers to have access to detailed Medicare data that shows what Medicare paid for a variety of different procedures - sort of a base set of prices. Then he looks at data for a broader set of these procedures and what patients (and their insurers) were charged for the same procedures. This identifies the general range of physician procedures, as well as the startling variances that can be identified, often associated with markups of 500 to 100%. From this data, he can draw some conclusions about whether physician practice is consistent with current science regarding best practices. Then he can also assess who is charging what - and who is price gouging. Put numbers on these transactions and it quickly becomes apparent where a lot of the Skyrocketing costs of health care are coming from. It is not a pretty sight.
  
  Another amazing aspect of the book is that there appear to be many ways to have health care go terribly wrong in terms of appropriateness so the chapters address different problem areas - each as ghastly as the next. The book begins with the efforts of some medical groups to recruit patients by free screenings at local churches in the poorer areas of the Washington DC areas. Hmm... lets say that these clinics do not fare well under the scrutiny of the Hopkins researchers - yes free, but inappropriate screenings for largely unnecessary stent procedures that Medicare will pay for (meaning the we will pay for). I was hooked after that chapter but it picked up afterwards. Other topics include: hospitals that sue largely poorer patients for nonpayment, inflated costs of helicopter transport services (cost of the ride greater than the cost of the helicopter), C Sections, Opoid over prescription, and the limits of “wellness” plans. This is only a limited list of topics. For all of these, the general problem is clearly presented in the context of a medical background that most laypeople could never hope to master. Do you want to know how to sign your forms if you need emergency care but are off network? This is the book for you.
  
  Dr. Makary also reports on solutions that show promise of “disrupting” the various middlemen parties that are gouging the health care system (PBMs, GPOs). These are interesting but much less compelling. The problems ar huge and baked into the system, a few innovative centers and new ventures here and there have little chance of really altering the system. Legislation is needed and Dr. Makary provides examples.
  
  The book is excellently written and makes only minimal numerical demands on readers. In addition, there are several scholarly journals by Makary and members of his team that can be consulted for additional details and further reading.
  
  I was surprised and pleased by this book and will read more of his work on accountable health care.