#68–Marty Makary, MD: US healthcare system—why it’s broken, how to fix it, & how to protect yourself

KEYPOINTS

• 01

  Healthcare delivery is a science, and the system is the problem

  Makary, a Johns Hopkins pancreatic surgeon and Attia's friend from their surgical training there, was drawn to patient safety by pioneers such as Lucian Leape and David Bates, then seen as radicals. They argued that you can study medical mistakes as rigorously as diseases. He insists that no single party is to blame. Hospitals, insurers, middlemen and doctors are all responding to misaligned incentives.

• 02

  Unaccountable and the surgical checklist

  His first book, a New York Times bestseller that inspired the TV show The Resident, grew out of stories his father urged him to write down during training. Makary is a co-creator of the surgical checklist adopted by the WHO's Safe Surgery Saves Lives effort. The checklist prevents errors like wrong-side surgery, which Attia saw happen in medical school.

• 03

  A small share of surgeons shouldn't be operating

  Makary estimates that fewer than 1% of the residents he saw at Hopkins were truly horrible. Nationally, he sees 5–15% of surgeons who should not be practising. Of the roughly 10% of doctors who contacted him about his provocative book title, most thanked him for speaking up.

• 04

  Honesty reduces lawsuits

  Makary and Attia's takeaway from the research is that the severity of litigation tracks what happens after an error, meaning whether patients are told the truth, more than the error itself. Patients crave honesty and transparency.

• 05

  Healthcare is now America's largest industry

  As of January 2018, healthcare was the number one US industry. Pittsburgh's skyline, once steel, is now dominated by health care, insurance and administration. Healthcare is about 18% of GDP. Makary says it takes about 43% of Massachusetts state spending, and US spending per person (about $12,000 a year) is more than double some countries'.

• 06

  Negotiated prices can be absurd, and insurers may not fight them

  An insurance actuary was billed $70,000 for a hip replacement that Medicare pays about $20,000 for, with a fair benchmark of $28,000–29,000. That was the negotiated price, not the sticker price. Part of the reason, Makary argues, is the Affordable Care Act's medical loss ratio rule. Insurers must pay out 80% of premiums in claims, so higher claims can mean more revenue.

• 07

  Middlemen and fake discounts add cost

  Makary uses a Girl Scout cookie analogy to explain pharmacy benefit managers. Attia says it took him two years to understand what a PBM did. Hospitals and insurers negotiate theatrical deals: prices up 15%, a 12% discount, and both claim victory. A 1987 law gave PBMs and group purchasing organisations protections that enabled the system. Makary estimates bogus discounts and middlemen at around 15% of spending.

• 08

  About 21% of care is unnecessary

  In a Hopkins survey of about 2,000 doctors, respondents said roughly 21% of healthcare services are unnecessary. Makary describes watching relentless testing on patients who don't want it. He also points to the US writing about 2.4 billion prescriptions a decade earlier, and to high-volume, under-resourced primary care that burns doctors out.

• 09

  Predatory billing ruins working families

  At a New Mexico hospital profiled in The Price We Pay, the hospital had sued about half of a 28,000-person town, mostly oil workers with insurance. The court clerk said around 95% of civil cases were hospital suits to garnish wages. Attia cites an estimate that one in four or five women treated for breast cancer is pursued by collections within about a year. Half of Americans have less than $300 in savings.