"It's the prices, stupid!". And they won't tell us what they are...

You wouldn’t buy most things if the price were not labelled, and certainly not if price were not available on asking. Sometimes shopping on the Internet is frustrating because that the prices are not always apparent. When I had to get my sewer routed out, the plumber told me what it would cos (a lot), and my only choice was to have a blocked sewer or try to find another plumber who might be cheaper. But I had that choice, and he told me the price. Even in the American bastion of car buying, where “negotiating” is a tradition, and while YOUR first question is “what is the price”, theirs is “what are you trading in [so we can quote a higher price]”, this is changing, with set prices at many dealers and alternative vendors like CarMax and Carvana.

Where it is almost never true is in purchasing health care, and it is worst when you are most vulnerable and in urgent need of a service -- sometimes even more urgent than routing your sewer line! We think we would almost never buy something first in order to find out what it cost – that would be crazy --  but in fact that is the title of a video by Martin Schoeller recently featured in the New York Times: ‘How Much Does Your M.R.I. Cost? Buy It First to Find Out.’ And that is what it shows. The prices aren’t available in advance, there is no published price list, there is no bar code for the clerk to scan, and no one, pretty much, can tell you how much it will cost. It is not just MRIs, of course; that is just the headline; it is all tests, procedures, surgeries, and consultations from specialists.

One of the people interviewed by Mr. Schoeller, who had severe injuries as a result of being two feet from where to bomb blew up at the Boston Marathon in 2013, says “I had these procedures done, and now I’m getting the prices. It should have been the other way; I should have had the prices first.” Of course. But this is the story all of the people he interviews – regular people, just like us, he notes -- whose lives have been upended twice, first by their health problem and then by the cost that they were never told about, “whether it is through surprise bills or straight-up price gouging.”

In an old expression, you might say “there oughta be a law”. The amazing thing is that there is a law, or at least a federal rule. The Hospital Price Transparency Rule went into effect on January 1, 2021. Per the website of the Centers for Medicare and Medicaid Services (CMS)

Hospital price transparency helps Americans know the cost of a hospital item or service before receiving it. Starting January 1, 2021, each hospital operating in the United States will be required to provide clear, accessible pricing information online about the items and services they provide in two ways:

1.      As a comprehensive machine-readable file with all items and services.

2.      In a display of shoppable services in a consumer-friendly format.

This information will make it easier for consumers to shop and compare prices across hospitals and estimate the cost of care before going to the hospital.

CMS plans to audit a sample of hospitals for compliance starting in January, in addition to investigating complaints that are submitted to CMS and reviewing analyses of non-compliance, and hospitals may face civil monetary penalties for noncompliance. Access a list of hospitals that have been issued CMPs.

That sounds good, right? There is only one problem. They’re not doing it. The article notes that “A recent study by PatientRightsadvocate.org, a nonprofit group that works for price transparency, revealed that only about 14 percent of the 1,000 hospitals it surveyed were complying with the new rule.” That’s right. Eighty-six percent of the hospitals in the US are NOT posting their prices, in violation of the law. While the language on the CMS website, “This information will make it easier for consumers to shop and compare prices across hospitals and estimate the cost of care before going to the hospital”, could have (actually, as far as I know, may have) come directly out of the mouths of a conservative think tank that advocates “consumer choice” as the solution to the costs of health care, they’re not even doing that. These folks want you to shop for health care like you would shop for anything else, choosing the one that provides you the most value for the best price. This was always a completely bad (I was going to say stupid, but it could be simply malicious) idea, but when you can’t even get the prices to compare, it is completely ridiculous.

Back on March 15, 2009 (“Bargaining down the medical bills”) I wrote about an Oprah Winfrey show on which her guests were the late health economist Uwe Reinhardt and Karen Ignani, the then-head of the trade group America’s Health Insurance Plans (ACIP). At one point

Oprah asked Ms. Ignani (and I paraphrase, I don’t have the transcript): “So if I need a $200,000 procedure, why don’t you just pay it?” Flustered, Ignani said, “Well, you presume that the $200,000 is in fact what the procedure is worth; other hospitals may chart less …” – Oprah interrupted her: “I’m sick!”, she said, “I don’t have time to go shopping around to six different places to see where I can get the best deal!”

I added “Unsurprisingly, the audience, made up of regular people, not pundits, applauded wildly.” But, in fact, in 2022, 13 years later, you still could not find the price for that procedure in 86% of American hospitals! Inadvertently, perhaps, Ms. Ignani points to another concern: your insurance company may refuse to pay for your procedure because you could have had it done across town (presuming you live in an area where there is more than one hospital) for less money. But, as Ms. Winfrey so succinctly put it, you weren’t in a position to comparison shop – you were sick!

The woman who was severely injured in the Boston Marathon bombing tells Mr. Schoeller that she had no idea that these surprise bills were coming, because everyone in the hospital was so nice. The fact is that none of those nice people, nurses, doctors, technicians, clerks, was being devious – they didn’t know the costs either. Mr. Schoeller says that it is not just patients, but employers, unions, even the government that cannot get the prices. And neither can staff. While most people would not buy groceries if the prices were not listed, some more well-off folks might. But only a very few would buy a car, or a house, or something else that might cost $200,000 without knowing the cost – unless it was medical care. Obviously, this hits the poor and uninsured worst, as does everything of the sort, but being insured – and even being well-insured – is not a guarantee that you will not be hit with surprise charges. And that you won’t end up like those who speak to Mr. Schoeller. One says “I just ignore the bills now,” and he asks if this might keep her from getting a loan or a credit card. “Of course,” she says. Life ruined?

So medical system IS systematically not only engaged in price gouging, but in fact hiding those prices in clear and direct violation of a federal rule that was put in place to address this problem. It is a system clearly and unequivocally built not to provide health care but to make money for the investors (in “for-profits”) and large organizations (“non-profits”) that provide the care, as well as insurance companies and drug companies and lots of large corporations, at the expense – in dollars and health – of all of us.

The same Uwe Reinhardt mentioned above, when asked why US health care was so expensive, was fond of saying (and co-wrote an article entitled) “It’s the prices, stupid!”. ‘“We depend on hospitals in our communities to take care of us,” Mr. Schoeller says, “But our hospitals are putting profits before patients.”’ He calls for there to be diligent enforcement and stronger penalties for violation of the price transparency rule.

It’s a good idea, but I call for more than forcing hospitals to post their prices. I call for those prices to be reasonable, and to require insurance companies to pay them, and for everyone to have health insurance that does. A universal national health insurance system, such as improved and expanded Medicare for All.

And the elimination of profit from the health care industry.

The new CDC "No Quarantine" recommendations: Do they increase your risk? (Spoiler: Yes)

Recently, the Centers for Disease Control and Prevention (CDC) revised its COVID-19 recommendations to eliminate the quarantine for infected people. Previously this had been reduced from 10 to 5 days. It is now not recommended at all, although masking for 5-10 days is still recommended after being infected, and there are suggestions -- “strategies that people may want to consider in order to reduce their risk” – such as avoiding crowded areas and maintaining a distance from others.

‘“We know that Covid-19 is here to stay,” Greta Massetti, a C.D.C. epidemiologist, said at a news briefing on Thursday,’ which about sums up their perspective. It is apparently their justification for the (lack of) safety recommendations and precautions. The author of the article notes that the loosening of the guidelines free ‘schools and businesses from the onus of requiring unvaccinated people exposed to the virus to quarantine at home.’

As far as that author (Emily Anthes) and the editors are concerned, there seems to be universal approval of this change from the medical and epidemiologic community, at least based upon those that are quoted in the article:

‘“I think they are attempting to meet up with the reality that everyone in the public is pretty much done with this pandemic,” said Michael T. Osterholm, an infectious disease expert at the University of Minnesota’; 

‘“I think this a welcome change,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. “It actually shows how far we’ve come”’ ;

‘“This really will help to minimize the impact of Covid-19 on education,” said Christina Ramirez, a biostatistician at the University of California, Los Angeles.’

One commentator, ‘Mercedes Carnethon, an epidemiologist at the Northwestern University Feinberg School of Medicine, said that she did not view the changes, even the elimination of quarantines in favor of 10 days of masking, as a loosening of the agency’s guidance.’

Dr. Carnethon continues ‘“We certainly know that wearing a high-quality mask is going to provide some of the strongest protection against spreading it to somebody else, and quarantine is logistically burdensome. That could be seen as a relaxing of guidelines, but I think it’s a much more appropriate and targeted solution.” Except, of course, that the CDC is not recommending that we mask in public areas. Whoops.

Ross Douthat, NY Times Op-Ed columnist, writes (Aug 13, 2022) that “The CDC continues to lead from behind”. His take is essentially that “everyone” has already been doing (or not doing) the things that the CDC is now recommending (or not recommending). I would agree that that is true (at least in the US), but to me it suggests that the recommendations are driven politically, not by “the science”.  Certainly it has been “an onus” for schools and businesses to comply with the recommendations (often conflicting) from different governmental agencies and others to protect their students, staffs, and customers. People do not like having to wear a mask in public, even in crowded indoor spaces, nor having to distance, nor staying home and quarantining and missing school or work. Or, even missing social interactions, from casual to parties. If CDC is “leading from behind”, making recommendations that much of the population has already been implementing, then this new step will encourage those who have already been doing so to further relax their carefulness. They may do so from a desire to get an education, make a living, interact with family and friends, or to party and use drugs or have wild sex, but these are, essentially, quantitative and not qualitative, differences. The fact that the article in the Times could not (or at least did not) find any countervailing views from epidemiologists, scientists, physicians, and other experts further endorses the “opening up” that people want. It is political in that having restrictive requirements is generally unpopular and could lose votes for politicians.

The only problem, of course, is that COVID is still out there and we are still at risk. What we are at risk for varies a lot, depending upon who we are, from “mild” illness (usually not so mild!) to severe illness to hospitalization, to death. The people who are most at risk are those who are immune compromised, either because of age, or illness, or (my favorite) the drugs that they are taking to treat illness, including the drugs widely advertised on television for cancer and rheumatic diseases. Plus anyone, of any age or prior health status, can get “long COVID”, with persisting symptoms that can be very severe and debilitating.

The World Health Organization observes that “7.9 billion people” (the world’s population) are still at risk for COVID, and that thousands are still dying every week. This poster makes those points, and also that new variants continue to emerge and can quickly become dominant. It also recommends things like keeping your distance and wearing a mask, abandoned by most Americans.

 

Of course, the risk of COVID also varies from country to country, which could justify why WHO and CDC have different recommendations. After all, in some countries there is greater risk than in others, and the struggle is just to keep their people alive. This might be reassuring to Americans if it were not for the fact that the US is one of those, remaining the leader in deaths.

(https://ourworldindata.org/coronavirus)

 

One of the key determinants of how a society functions is the balance between the rights of an individual to do what they want and the benefit to and protection of society. In the US, we have always tended toward the individual, but public health laws, regulations, rules, and recommendations are based upon the benefit to society. This makes sense because infectious diseases do not limit themselves to only those people who have consciously and willingly made the decision to take the risk of acquiring them. They also affect those who, absent governmental requirements to protect them, are forced to come to work and risk being infected or lose their livelihood, and those who are old or sick but come into contact (even in families) with those who have acquired infection because protecting themselves was just too much trouble.

The logic is flawed; what if laws against killing and stealing were made recommendations to be adopted by those who wished to be cautious? It would not just affect those who made the decision to not adopt them. Sure, we have people killing and stealing and being killed and being robbed despite the laws against it, but those laws protect us far more than a general recommendation that folks not kill or steal would. So too it is with the virus; if you go shopping and few others are wearing a mask despite rules or recommendations that they do, you are at risk. If those rules are repealed and the recommendations rescinded, then more and more people will think they are safe not doing so.

Vaccines are good and protect a lot. They do not by any means eliminate the danger. The changes in recommendations mean the politicians to whom CDC answers will be more popular, and be more likely to get re-elected.

And that more people will die.

Who should we take in medical school? What should be the criteria? Who will be a good doctor?

There are many serious inequities in our society, and they tend to build upon one another. People with more advantages have more opportunities to do well themselves, and those with fewer have less. Those advantages (or, conversely, disadvantages) include wealth, white race, male  gender, suburban or urban (but not poor areas) location, and education. All these feed one another. For example, coming from a well-to-do family and being white dramatically increase the odds of success in a chosen field. Even if there were no discrimination against people based on race and color (and this is a long way from being true), there is still the fact that people of color are grossly over-represented in low-income communities and families. This is a clear example of structural racism, so that effective discrimination based on class disproportionately falls on people of color.

An important manifestation of this exists in healthcare, and in particular the production of healthcare professionals (but also in other professional fields). In medicine specifically, we have a physician workforce that does not reflect the population of the US in terms of class (or family income), race, gender (although this is the area in which the greatest progress has been and continues to be made), geographic location (rural vs. urban), and specialty choice. Our doctors overwhelmingly are from upper-middle-class backgrounds, are white, are from suburban (or well-to-do urban) communities, and largely male. They practice in urban and suburban areas in even greater proportion than they come from them, in part because they also practice in specialties and subspecialties that cannot survive in smaller communities, rather than in family medicine and other primary care specialties that are in shortage. This exacerbates the other inequities by making healthcare something that is less accessible to many Americans based on geography (where are the doctors located?) and culture, as well as because of cost, the absence of a universal affordable healthcare system being an almost uniquely American phenomenon.

Not having a medical workforce that looks like America, or practicing in the areas and specialties where there is most need, goes beyond the admissions process to medical school. It is impacted by the curriculum (both formal and informal, or “hidden”) in medical school, by role models and mentors, and very much by the potential income from practice. The systemic characteristics of society greatly influence who is considered a “good” candidate for medical school, and even who applies. These are considerations addressed in a recent blog post on LinkedIn®, a professional networking site, by Dr. Heidi Chumley, dean of the Ross University School of Medicine (RUSM). Dr. Chumley focuses on the challenges faced by students from backgrounds underrepresented in medicine (URiM), and in particular on the emphasis on performance on the Medical College Admission Test (MCAT) for deciding who gets into medical school, since URiM students perform less well on that test. She notes that what seems like a small difference in scores makes a significant difference in admission: “There remains an unexplained gap in average MCAT scores between White (503.1), Black (494.9), and LatinX (497.1) test-takers. This gap matters as 29% of applicants with a score of 502-505 are accepted compared to 10% with a score of 494-49.”

Dr. Chumley also address two other critical points. First, that the lower MCAT scores are likely tied to many of the social and educational disadvantages faced by URiM students, thus reflecting, and compounding, the other factors that these students have to overcome. Second, that efforts implemented by many medical schools (and endorsed by the Association of American Medical Colleges, AAMC) to have a more “holistic” admissions process mostly changes the selection of which high-scoring students are admitted. Yes, it is great that students who have a social conscience and have done volunteer work in the US and abroad are selected over those who are selfish and not so involved, but this rubric, as she points out, ignores the fact that many lower-income (and URiM) students need to work at paying jobs to support themselves (and often their families), and devalues such employment in comparison to the voluntarism that is more accessible to those from privileged backgrounds.

Added to this is the financial component of the cost of medical school itself, which, in the US and in the US (and Canadian) serving Caribbean medical schools (of which Ross is one of the largest and most prominent), is staggering. Students typically graduate from medical schools with debt loads of $250,000 or more. In addition to being outrageous to start with, add the fact that compound and accrued interest makes the total to be repaid much higher, and this encourages students to choose higher-paid specialties even when that is not where the greatest need is (you may make, over a lifetime, $7M more practicing as, say, an anesthesiologist compared to a primary care doctor) or even where the student’s personal interest lies.

Dr. Chumley describes some of the efforts to increase access for URiM students at RUSM, and they are indeed impressive. They include “pipeline” relationships with HBCUs (Historically Black Colleges and Universities) and HSIs (Hispanic-Serving Institutions) and  re-thinking what criteria for admission are essential, valuing the life experience (including work experience) of applicants and putting less emphasis on the absolute score students get on the MCATs. As she points out, the MCAT predicts performance on similar multiple-choice tests of knowledge including most “pre-clinical” tests in medical school, and the licensing exam, the USMLE (particularly Part I, which covers basic science). It definitely does not predict performance as a good or excellent clinician. Also, while there are significant differences in the first-time pass rates on USMLE in those who score “over-500” (> 95%) and “just under 500” (> 80%) groups on the MCAT, the medical school curriculum should be addressing those differences.

The two points I would like to emphasize are the criteria for who is likely to become a good doctor (and thus should preferentially be admitted to medical school) and the enormous cost burden on medical students that obviously falls hardest on those with the least wealth. As I have said before (The high cost of medical education: Who should be trained to become doctors?, Dec 10, 2019; Free tuition in medical school is only one step toward producing the doctors America needs, Aug 26, 2018), those who should be given the opportunity to become doctors (ie., be admitted to medical school) should be those most likely to make a positive difference in the health of our population. This includes a sense of community over self, a willingness to serve where needed, and interest in (preferably commitment to) practicing the specialties most in need in the areas most in need of them. Since URiM doctors are more likely to practice with patients from similar backgrounds (and those patients are often more comfortable seeing them), and a comparable correlation exists with those from rural backgrounds, these characteristics should be very important criteria. As should coming from a family with lower than average wealth and income, which requires addressing the second point. Higher income does correlate with better education and higher MCAT scores, and maybe higher scores on basic science tests in medical school (which are very like undergraduate science tests) and USMLE Part I scores, but not (and almost inversely) with practicing the specialties most needed and caring for the people most in need. So this should at best be a neutral, not positive, criterion.

And the money is a big one. You can admit a student from a low-income family who will be a great doctor, but they should not have to go into absolutely crushing debt and certainly not to enter the highest-income specialties to pay it off. This can partially be addressed by medical schools offering scholarships and states and localities offering loan-repayment programs, but it would be most effective if the federal government could subsidize the cost to make it far lower, and in conjunction with requirements that schools (state or private, stateside or Caribbean) to produce the physicians America needs.

Of course, as well, and even more important for all our people, to have a free or very low cost universal health system.

 

Disclosure: Dr. Chumley and I have known each other for many years and previously worked together.