My Bitter Pill

Steven Brill’s “Bitter Pill: Why medical bills are killing us”

Bruised, stunned, winded, exhausted, frustrated. That is how I felt after reading a lengthy but impressive piece of journalism, Steven Brill’s featured Special Report in Time magazine. Although almost as long as a small novel, Brill’s article was insightful for me as a medical student and as a future physician.

UPDATE 6, 2017: Adam ruins everything made a video about this topic! https://youtu.be/CeDOQpfaUc8

Through several anecdotes Brill uncovers what happens when patients pay for their health care with no insurance, with minimal insurance, with good insurance, and with medicare. Brill follows the perspective of these patients and then follows their money.  In one of these anecdotes a patient went to the ER for chest pain. When that patient received the details of their bill, it stated one troponin test had cost $199.50! In my clinical experience, we usually order a series of three of these because they are vital for ruling out a heart attack (troponin measures myocardial damage).

But why is this cost so high?! Brill chases this down and is relentless about it. He finally finds out from hospital administrators about something I’ve never heard of: the chargemaster. The chargemaster is a hospital’s internal price list. As you continue reading, you see Brill uncover that everything about this list is illogical and shady. Administrators deny that the list is relevant because patients rarely pay this full price. Yet as Brill shares several other stories, we see that this is not true. Patients still end up paying prices as stated on the chargemaster regardless of their insurance.

Health, politics, and money

The rest of the article is brilliant. If you are a health care worker, a voting citizen wanting to be informed, or (God forbid) a future patient then read the article. Here are a few tidbits that were supreme:

Unlike those of almost any other area we can think of, the dynamics of the medical marketplace seem to be such that the advance of technology has made medical care more expensive, not less.

However, no matter how steep the discounts, the chargemaster prices are so high and so devoid of any calculation related to cost that the result is uniquely American …  As with the local electric company, customers must have the product and can’t go elsewhere to buy it … But unlike with the electric company, no regulator caps hospital profits.

Health care is seen as even more of a necessity than higher education

“They hand out blood tests and X-rays in hospitals like bottled water, and they know it.” … But conflicts that may encourage devices to be overprescribed or that lead doctors to prescribe a more expensive one instead of another are not the core problem in this marketplace.

Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.

Put simply, the bills tell us that this is not about interfering in a free market. It’s about facing the reality that our largest consumer product by far — one-fifth of our economy — does not operate in a free market.

Our American culture of health care

At the macroscopic level, I felt the article uncovered some themes unique to our American “health care culture.”

• We like discussing who is going to pay for health care instead of why our health care is expensive.
• We don’t like transparency because it will make us negotiate our sense of entitlement.
• We really believe in the power of money and technology over death and life.

A theme that I want to explore is about technology and its relationship to health. Technology is a beautiful and God-given gift that has certainly improved the quality of life in our society. But when we see a family spend almost a million dollars when someone has a catastrophic health event something must be wrong! Families live years after an event with millions in debt to pay. It’s only in America that patients (myself included) will spend exorbitant amounts of money to live only a few years longer. In other countries with different health cultures, it is easier to accept that someone is going to die and to forgo the expensive heroic medical measures that Americans so easily accept.

This is a complicated ethical issue and the answer lies between doing every heroic measure possible to save a patient and coercing every geriatric patient into DNR. My point is simply to find a balance and to take responsibility. It is not just our patient’s fault. It is our physician’s fault. It is the hospital’s fault. It is our culture’s fault. It is the American belief that we have the right to live beyond our means. If you ever finish reading Brill’s article, you will see that American culture enables us to forgo responsibility of the power that technology has over health.

Be a leader, take responsibility

Brill offers a strong argument at the end of the article with some practical ways our society can change. With this in mind, I need to ask myself how I can take part in the solution. What can a doctor really do about our nation’s health care as a whole? How can a doctor take responsibility instead of shifting blame or whining?

Ever been in a relationship? If you have, then you realize that if you don’t heed other people’s wisdom, you will learn from experience. The health care game is almost like being in a long-term relationship where every new fight resurfaces old hurts and unforgiven bruises. You know that you’ve done wrong. You know that the other person has done wrong. Yet both of you are not willing to take the blame.

But as couples in successful relationships have learned (or so I’ve heard), someone just needs to mature and take responsibility. I think the same holds true for health care. I’m only a medical student. I will only be one doctor. I am not entirely responsible for this mess, but I am still responsible. I need to do my part. As a medical student, maybe I need to speak up and question if morning labs are really that necessary and would affect the course of treatment. As a resident, maybe I should think about the cost of every order I give and determine for myself if it is medically needed. In the future as a physician, perhaps I need to accept that I may become more overworked or even more underpaid. Perhaps, I need to accept that being sued by the people I try to help is worth it if I can heal others.

I need stop talking about who should be responsible, but to take responsibility and let go of my feelings of entitlement. Doctors are trained to make wise decisions in a limited amount of time under stressful circumstances. In the hospital, doctors are accountable at the end of the day. If doctors were trained to be responsible leaders, then why does health care look like a terribly managed and neglected patient?

Reading Brill’s article really made me sit down and think. It made me pause and take a step back from my fast-paced and stressful medical school experience. What am I doing all this for? Am I going to just sit back and go through the motions of my medical career? The only way I would be motivated to care is if my motivation as a doctor will be the same as someone who is in love with their partner. If you know what I am talking about, then you will know that although taking responsibility is gut-wrenchingly hard sometimes, it is worth it in the end.

To heal is to “count others more significant than yourselves”

The last theme I sensed in the article was about how people see life and death. By mixing religion, modern philosophy, politics, and money into a capitalistic society, you get one monstrous mess of health culture belief about life and death.

When we speak about beliefs we speak from our identities. While I am a medical student and a future doctor I am also a Christian. Part of being a Christian is realizing that life is not about health but about healing. Our imperfectness or sin offends God and because He is perfectly just we cannot enter a relationship with Him unless that is fixed (just as a judge cannot forgive every person, otherwise they wouldn’t be a good judge). But because God loves us, God sent Jesus to be the mature one, to take responsibility and pay our debt (just as a lover would take the blame during a fight so the relationship can continue). Being Christian does not mean your goal in life is to live a long life nor to get to heaven. Life means to know that Jesus died to heal our relationship with God and to love Jesus for doing that. Period.

So when Christians talk about health care, life, and death, they need to talk about Jesus. This is what I don’t see many people do. Nor do I really see formal religious organizations making noticeable headway. Christians don’t need to force religion down people’s throats but we need to really believe what we already know is true for us. If Christians really believe Jesus is “the way, the truth, and the life”, then when Christians talk about health care, they need to show that healing is meant to show who Jesus is.

One of my favorite lines of scripture states, “Do nothing from selfish ambition or conceit, but in humility count others more significant than yourselves.” When I am sincerely taken care of and feel like someone treats me more than I deserve– I feel loved and I feel healed. What amazes me isn’t only that humans do this to one another, but that God did that for us.

Philippians 2: 2-11

So if there is any encouragement in Christ, any comfort from love, any participation in the Spirit, any affection and sympathy, complete my joy by being of the same mind, having the same love, being in full accord and of one mind. Do nothing from selfish ambition or conceit, but in humility count others more significant than yourselves. Let each of you look not only to his own interests, but also to the interests of others.

Have this mind among yourselves, which is yours in Christ Jesus, who, though he was in the form of God, did not count equality with God a thing to be grasped, but emptied himself, by taking the form of a servant, being born in the likeness of men. And being found in human form, he humbled himself by becoming obedient to the point of death, even death on a cross.

Therefore God has highly exalted him and bestowed on him the name that is above every name, so that at the name of Jesus every knee should bow, in heaven and on earth and under the earth, and every tongue confess that Jesus Christ is Lord, to the glory of God the Father.

As a physician, you can influence if a person needs medicine or not. As a physician you can teach a patient what is healthy and what is not. As a physician, you can help people discern what is important in life and what isn’t. Be brave and take a stand for what it is you believe in. “Do this not out of selfish ambition but in humility.” As a Christian, I believe in a God that in humility became a servant to heal the sick of this world. Just as Jesus took his “bitter pill” in order that we may be healed, I must take responsibility as a future doctor so that healing can continue.