"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.

"People will believe anything": Snake oil salesmen and bad health advice

The other day, I took a nephew to see the new Spider Man movie, “Far from home”. No review here; just to say that a big part of the plot revolves around the bad guy using a high-tech virtual reality system to project fake images that everyone takes to be real. Several times in the film he and his henchmen say “people will believe anything”. The parallels to the daily reality of our times, to “fake news” and distrust of science, are too obvious to be coincidental. Of course, in the movie the bad guy loses and the good guy (Spider Man) wins.

It is still far from clear if the “good guys” (and here I speak not of specific individuals, but of those who advocate for truth, a real reality, and science) are going to win in the actual world. The forces of darkness and reaction, wearing the face of Donald Trump and facilitated by the Republican Party, but actually representing and funded by the corporate elite – gangster capitalists – may not wear capes and fly around or use astral projection, but they have enormous resources to control the dialogue, provide misinformation, and serve themselves. They are resilient not only because of their wealth and power, but, sadly, because so many people are happy to try to deal with their own oppression by hating, oppressing, and believing bad things of others.

Health and medicine are clearly not immune from the reach of “fake news” and false beliefs and those willing to exploit our willingness to believe what we want to be true rather than what is. This is often a result of also a logical fallacy, wishful thinking (which is only a fallacy when it is expressed as true; not when it is expressed as a hope or wish) but may be more appropriately called “magical thinking”, a developmentally appropriate stage for young children that is always pathological in adults. Those who promulgate false scientific, medical and health theories and advice can be doing so to make money, to exert power and control, because it derives from a pre-existing belief (sometimes but not always religious). Sometimes it is also self-delusional, especially when the proposed solution is easier, more palatable, less painful, and requires less discipline than the medical alternative (take these simple pills – or snake oil -- and you won’t have to diet/exercise/stop smoking or drinking/have radiation or chemotherapy or surgery and you can be more youthful or beautiful or sexual). I once wrote about a patient who was obsessed with getting mammograms for breast cancer, a condition for which she was not at elevated risk and was far too young for routine screening, but was uninterested in addressing her actual risks resulting from heavy smoking, uncontrolled high blood pressure, and unprotected sex with multiple partners (Healthful Behaviors: Why do people adopt them? Or not?, October 8, 2011). Because, I inferred, it was easier, and would require no real effort or difficulty on her part. This is why it is an attractive option. But it is not a good idea.

The trend toward getting health and medical advice from those who are not medically trained has always been with us, but the same easy dispersion of information (or misinformation) through the Internet that allows us to hear anything we want and, to a large extent, only what we want, impacts health care as well as politics. The “anti-vax” movement is very popular, and promoted by celebrities. (Why should we not get our health advice from those whose qualification is that they are celebrities?) In addition to being wrong, it is very dangerous to the public health. I say that with absolute certainty. The anti-vaxxers are wrong. Period. There is some risk that individuals will have a reaction, very rarely a serious one, but this impact is totally miniscule compared to the benefit of preventing disease through vaccination. Indeed, vaccination is one of the few areas in which we actually can prevent, and thus not have to treat, diseases!

Some celebrities deserve a special call-out for their comprehensive and ubiquitous denial of fact, reason, and science – amazingly, often in conjunction with a profit motive from the brand of snake oil that they are selling; Gwyneth Paltrow is the exemplar. Of course, Ms. Paltrow deserves some credit for being able to convince people that they should do things that are actually unpleasant and painful for the sake of their health and beauty, like getting stung by bees, even though these are of no actual value to her clients. Obviously, they are of financial value to her. And, while I admire much of what she does in the world, Oprah Winfrey is also a big proponent of false health information.

Sometimes, bad policies are advocated by the self-righteous, as is the case with the current Israeli Education Minister, the most recent bigot coming out for “conversion therapy” for gay people. This is an example of falsely medicalizing a condition by suggesting it requires therapy, something that should not be. Sometimes, as in Paltrow’s case and many others, it is at least in part motivated by the opportunity for profit. Often, and this is sad, it is motivated and believed because people do not trust doctors and other health professionals. One reason it is sad is because people eschew treatments that could be of benefit to them in favor of those that will not help and may even hurt. But another major reason is that many doctors and other health professionals have been themselves guilty of pushing treatments that do not benefit, and may hurt, their patients. They do this for the same set of reasons as those I criticize above: to make money themselves, to make money for drug and device makers who pay them directly or in gifts including drug samples, because they are too lazy (or “too busy”) to actually read and evaluate the evidence and so taking the advice of drug or device salespeople is easier, and because they think that because they are doctors everything they think is right. I wish this were not true, but it often is. Holding physicians to a higher standard than non-medical people is appropriate, but this is not an argument for believing people because they are not doctors, no matter how confident. Iit absolutely in no way justifies listening to the advice of non-medical people who know even less!

It is also the case that some “alternative” suggestions for treatment are helpful, and many others are probably benign (except for the cost), even if the evidence is that they are not helpful; one example is taking vitamin supplements. If you can afford them, and don’t take excessive doses, they probably don’t hurt. It is certainly a better way to waste your money than on cigarettes, but if you can’t afford them, skip them. Other medical interventions can be good, and of benefit, but the benefits are often overstated, or reified as totally important. This is especially true when it is promoted as more “natural”, a word so overused as to have almost no consistently definable meaning. One example might be the use of birth attendants, called doulas. For many people, especially those who do not have a support system such as a spouse or parents or siblings or friends (and, likely for some who do) it is very helpful to have a knowledgeable, supportive person during your labor, focused entirely on you. But they are neither magic nor necessary.

Having someone who can help you deliver your baby, like a midwife or physician, is often necessary. A birth support attendant is a nice addition. Nurse-midwives train as registered nurses then do additional years of midwifery training and attend many births, including many doing deliveries under supervision. They can deliver babies as well as support women in labor.  In contrast, becoming a doula, according to https://www.naturalhealers.com/midwifery/doula requires a total of about 2-3 weeks including the need to attend a few births. So what scientific basis could there be for NY State Gov. Cuomo is advocating the expansion of the use of doulas to decrease maternal mortality, something for which there is not only no evidence, but no rational basis for thinking.

Come on, Governor! Come on, people! Not harmful is good, helpful is even better, not breaking the bank is important, and sometimes natural is nice. But let’s not choose magical thinking over science. That helps no one, except the snake oil vendors.