The Peter Attia Drive - #68 - Marty Makary, M.D.: The US healthcare system—why it’s broken, steps to fix it, and how to protect yourself

Episode Date: August 26, 2019

In this episode, Marty Makary, Johns Hopkins surgeon and NYT bestselling author, discusses his ambitious attempt to fix the broken U.S. healthcare system through educating the public, changing the lexicon, encouraging radical transparency in pricing, and more. We go in detail into the main drivers of inflated health care costs, the money games being played making it hard to understand, and the unfortunate system structure that has resulted in one in five Americans finding themselves in medical debt collections which can ruin the lives of people and families seeking basic medical care. Marty also shares some very practical advice and tips if you find yourself a victim of predatory pricing and stuck with an outrageous medical bill. In the end, despite the current state of the system, Marty discusses the many exciting trends gaining traction in healthcare and why he is very optimistic and hopeful about the future. We discuss: The science of delivering healthcare, how we need to do better as a system, and why no single person or entity fully to blame [10:15]; The stories that prompted Marty to write his first book (Unaccountable) [19:15]; The Surgery Checklist [26:15]; The problem is with the system (not any one person or entity) and the misaligned interests of all the parties involved [28:15]; Patients crave honesty and transparency, and the story of Peter’s back surgery gone wrong [33:00]; Today’s med students and young doctors have less tolerance for predatory pricing and healthcare industry BS [44:30]; Funny stories about John Cameron (legendary surgeon at Johns Hopkins) [48:00]; How doctors are trained to internalize traumatic experiences which can result in a misunderstood form of “burnout” [57:40]; The beat down of med students with traditional medical education and some exciting innovations to medical education [1:07:00]; Exciting trends in healthcare and an optimistic view of the future [1:11:30]; The Price We Pay (Marty’s new book), an attempt to illuminate the blackbox that is the US healthcare system [1:21:00]; Why it’s not always in the best interest of the insurance company to negotiate the best price [1:28:30]; Who is actually paying for medical costs, and Marty’s frustration with the healthcare lexicon [1:32:00]; Pros and cons of a single payer system [1:37:00]; How to fight outrageous medical bills and predatory pricing (and make a dent in the wasteful healthcare spending for the country) [1:49:30]; Disrupting the healthcare industry with private healthcare facilities with market demanded transparency [2:05:45]; The people hurt the worst by the current US healthcare system, the sad breast cancer statistic, and the importance of knowing that medical bills are negotiable [2:09:30]; The healthcare industry bubble [2:14:00]; Increased costs from unnecessary tests and procedures [2:16:30]; Malpractice concerns due to the litigious culture in America: What influence does it have on unnecessary testing, healthcare costs,  and overall quality of treatment  [2:22:00]; Drug pricing, price gouging, middle-men money games, kickbacks, and other drivers of healthcare costs [2:27:45]; How can we possibly fix the healthcare system? [2:34:30]; Helpful resources [2:46:15]; and More. Learn more: https://peterattiamd.com/ Show notes page for this episode:https://peterattiamd.com/martymakary/ Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful, top-performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peterottiamd.com. Hey everybody, welcome to this week's episode of The Drive. I'd like to take a couple of minutes

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that helps me continue learning and sharing this information with you. To take one example, our show notes are in a league of their own. In fact, we now have a full-time person that is dedicated to producing those, and the feedback has mirrored this. So all of this raises a natural question. How will we continue to fund the work necessary to support this? As you probably know, the tried and true way to do this is to sell ads. But after a lot of contemplation, that model just doesn't feel right to me for a few reasons. Now, the first and most important of these is trust. I'm not sure how you could trust me if I'm telling you about something when you know I'm being paid by the company that makes it, to tell you about it. Another reason selling ads doesn't feel right to me is because I just know myself. I have a really hard time advocating for something that I'm not absolutely nuts for.

So if I don't feel that way about something, I don't know how I can talk about it enthusiastically. So instead of selling ads, I've chosen to do what a handful of others have proved can work over time, and that is to create a subscriber support model for my audience. This keeps my relationship with you both simple and honest. If you value what I'm doing, you can become a member and support us at whatever level works for you. In exchange, you'll get the benefits above and beyond what's available for free. It's that simple. It's my goal to ensure that no matter what level you choose to support us at, you will get back more than you give. So for example, members will receive full access to

the exclusive show notes, including other things that we plan to build upon. These are useful beyond just the podcast, especially given the technical nature of many of our shows. Members also get exclusive access to listen to and participate in the regular Ask Me Anything episodes. That means asking questions directly into the AMA portal and also getting to hear these podcasts when they come out. Lastly, and this is something I'm really excited about, I want my supporters to get the best deals possible on the products that I love. And as I said, we're not taking ad dollars from anyone, but instead what I'd like to do is work with companies who make the products that I already love and would already talk about for free

and have them pass savings on to you. Again, the podcast will remain free to all, but my hope is that many of you will find enough value in one, the podcast itself and two, the additional content exclusive for members to support us at a level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn from and find value in the content I produce, please consider supporting us directly by signing up for a monthly subscription. My guest this week is Dr. Marty McCary. Marty is who's a close personal friend from residency. We overlapped when he was a fellow at Hopkins and I was a resident. He's currently a professor of surgical oncology and the chief of

the Islet Transplant Center at Johns Hopkins. And while so much of his work and professional accolades come from his surgical career and the work that he does in pancreatic surgery, especially in minimally invasive pancreatic surgery, Marty is one of the pioneering surgeons in doing one of the most complicated operations that's ever done, which is removing the head of the pancreas minimally invasively, meaning laparoscopically, something I can't even fathom because at the time of my training, that wasn't even something that was considered. We actually don't touch on that one bit because there's so many other things that we really wanted to talk about. The other thing that Marty's really known for is being one of the co-creators of the surgical checklist. And this

is something that has made its way up to the WHO Safe Surgery, Save Lives Committee. Today, many of you, if you're ever in the hospital, if you're ever having a surgical procedure, will encounter this checklist because it's the thing that makes sure that people don't get operated on the wrong side, which is actually something that happened to me when I was in medical school. And it actually is something Marty wrote about in his first book, which was a New York Times bestseller called Unaccountable. And it's actually that book that became the basis for a very, very popular television show called The Resident, which is based on Marty's work. We touched on that briefly, but most of what we talk about is the material and the content that's featured in his upcoming book, The Price We Pay, which will be available shortly. And this book really takes on Marty's next challenge because if

figuring out a way to do the most complicated pancreatic surgery from a minimally invasive standpoint wasn't enough, and then going after medical errors and trying to figure out a way to fix the system that makes it too easy to commit medical errors. Well, if that wasn't enough, you know, Marty's decided the next thing that he's interested in trying to address is the broken healthcare system, which I think anybody listening to this knows in the United States is pretty clear. What I like about Marty is he isn't one of these guys who's trying to put the single silver bullet and blame it all on one thing. Oh, it's all drug prices, or it's all this, or it's all that. What follows is a pretty nuanced discussion that it sometimes makes me really upset. There were times during this interview when I just couldn't believe the stories he was telling. And I think

many of you will be equally upset by these things and find it totally unacceptable. But at the same time, when it was all said and done, and as is often the case when these podcasts finish and the mic is off, we keep talking. And I think to myself, oh, I wish we recorded that because that was probably the most interesting part of the discussion we had. But I actually came away before Marty left my apartment, I came away realizing there's actually hope here. And I've actually never felt that there was hope for this problem. I truly thought that the US healthcare system is something that will drive itself off a cliff until it bankrupts us. And that is the end of it. And I came away from this discussion thinking, no, there are actual steps that could be taken to fix the structural errors that have allowed people

with, in some cases, very good intentions, in some cases, reasonable intentions, and in rare cases, horrible intentions to basically create the most financially irresponsible system that I think has ever existed in the free market. If you're listening to this and wondering why does this concern you, I believe it concerns almost anybody because anybody who's ever received an explanation of benefits that made no sense, anybody who's ever received a medical bill that seemed ridiculous, anybody who's ever known anyone who's been chased down by a collections agency, which sadly, the numbers of Americans who experienced this is staggering. You'll want to listen to this because I thought I understood this system well enough that I could coexist with it. I learned so much from Marty

about what people can do to protect themselves from this sort of predatory pricing that is, I mean, literally gouging the pocketbooks of people. I think if nothing else, you will come away from this episode with a greater sense of empowerment and how you can protect yourself in such situations and protect the people that you care about. I'll share with you just one statistic that breaks my heart. the people that you care about. I'll share with you just one statistic that breaks my heart. I believe it's one in four, maybe one in five women who undergo treatment for breast cancer about a year after their treatment is currently being pursued by a collections agency for some sort of ridiculous predatory pricing scheme that resulted from the treatment. To know that a

patient now, based on some of the work that Marty has done, have steps that they can take to put an end to that kind of stuff and fight for their rights is just one of the many things in this episode that kind of gave me some comfort. So without further delay, please enjoy my conversation with my good friend, Dr. Marty Macri. Hey Marty, how are you, man? Great to see you, Peter. I love that I can see you twice in two days. It's awesome. Awesome. Proud of you, everything you're doing, helping a lot of people out there. So just really great to see you. Yeah, well, not as many as you. You know, it's funny, whenever I'm doing a podcast, I'm sort of going over a person's bio. And I've had

the luxury of interviewing a number of friends for this podcast. And so I'm thinking to myself yesterday, I don't really need to review Marty's bio. I know Marty, but my team was kind enough to pull the bio together and they sent it to me and I was reading it and I was like, God damn, what happened? How did all of my friends leapfrog 27 steps ahead of me? And I say that without any envy, just complete admiration. I was with Jorge Salazar a few months ago. And it's just another one of those examples of like all these guys that we trained with. Ted Schaefer is the head of urology at Northwestern. Jorge's building the pediatric cardiac surgery program in Houston. I'm like, when did Marty even become a professor? How did you fully, I mean, dude, you are accomplished, man. Hopkins is a special place, just as you've suggested.

And I love it, just as you loved it there. But I've always had a special affinity for individuals that are highly creative, a little too creative for the mold in medicine. And so you're one of those guys. That's why it's just so great to see you here and be with you. That's a kind way of putting it. There are a lot of things I want to talk about. But among them, of course, is you've got a new book that's coming out really soon.

And this is your third book, but really your second on the topic of medicine in a pretty serious way. Let's start with your first book though, because that was, God, that's almost 10 years old now, isn't it? Yeah. Unaccountable. It's coming on eight years. Yeah. Eight years. What prompted you to write that? And of course, what some people probably don't know is that a show that many people love called The Resident is actually based on that. We'll talk about the show in a minute, but let's talk about the book Unaccountable.

Yeah, Unaccountable to me was an opportunity to talk about what we all talk about, but engage the general public in a way that both brings honor to medicine and at the same time warns people that it's important to get a second opinion. It's important to ask certain questions. I've always been amazed, even from my days as a medical student, where I was lucky enough to work with two of the leaders of the field of patient safety, Lucian Leap and David Bates at Harvard. And at

that time, they were sort of radicals. They were talking about, hey, not only can you study infectious diseases or cancer, but you can study the science of delivering health care, like medical mistakes and how that harms patients. And then you go from that academic concept to surgical residency, where it's like you can debate on a policy level, should we ration care? But like on call in the trauma bay, you're rationing care every minute. It's like, look, on the ground, it's a different world. It's relentless.

And they seem completely detached, by the way. Completely. Like there's nothing in residency that, and maybe it's changed, but I'm guessing it hasn't changed that much. There is nothing to prepare you for or teach you about those types of questions and decisions. Exactly. When I was at DC General City Hospital in Washington, DC as part of my residency at Georgetown, and there was an open elevator door and somebody walked into the elevator

shaft thinking the elevator was there, but it was just the shaft. Oh my God. And fell in and died. I don't mean to make light of it, but it was a tragedy. And they had her picture up everywhere. And the door remained in the open position with the open shaft for three more weeks. Haven't we learned our lesson? What do you mean?

They didn't put a barrier? There was no barrier. There was no cone. There's no do not cross tape or anything. And to me, this was like the ultimate story of how hospitals were not learning from their own mistakes. And three weeks later, another person walked into this opened elevator shaft and didn't die, but fell down and hurt themselves.

You just think, who is watching out for the whole ship? Who's in charge here? And those sort of experiences, and we see them all the time as residents. You'd see the elevator button wasn't working to the helipad, or the person in the x-ray counter refused to give you x-rays because they had their own little policy that they made up. And you're just like, can't somebody just look at the whole picture? So it made me think about systems, hospital systems, redesigning the delivery of care.

And I think all of those questions naturally open up the question of how can we do better? How do we harm people? And the lexicon is tricky, right? Because if you call it a medical mistake, doctors get very, very defensive. And we work so hard to get to where we are. By the way, John Cameron, who people may or may not know, may be the most famous surgeon in the United States. I spoke with him just before I came here. And he told me, oh, you're going to see Peter Attia. He was the best resident we've ever had at Johns Hopkins. And when you did your time at the NIH in research,

he said Steve Rosenberg, who's head of the NIH science surgery side, said Peter was the best researcher we've ever had at the NIH doing his research here. Anyway, we work our tails off in that residency, right? And then to have someone say, oh, you screwed up. It's like, well, wait a minute. It wasn't me. It was the system or I'm overloaded. And the reality is it is a systems issue. So the lexicon is important. If you call something a medical mistake, then it assumes you're blaming somebody. But if you say the patient experienced medical care gone wrong, it's a more patient term. Now we have a lexicon in medicine that sterilizes everything. We call things a preventable adverse event.

It just kind of washes anybody clean of any responsibility. Right. But it's medical care gone wrong. And in the pricing world, it's the same thing. If you talk about healthcare costs, it's kind of nebulous. But if I told you the price of healthcare has gotten out of control, it's like talking about gas prices versus petroleum futures or something. It hits home. Medicine has a way of creating its own lexicon, and it really has a value system behind it. So one of the things I've tried to do, at least with the platform that I've been given from my surgical career at Hopkins, is say,

how can we change the lexicon? How can we look at the systems and the delivery of care? How can we make sure somebody's in charge of the overall ship. So the elevator door closes or somebody for the love of humanity, put a cone in front of an empty elevator shaft. We laugh at that example, not as you said, because of the tragedy of what took place, but because of the absurdity of it. But what's really scary is the far less absurd errors that take place. And I knew we were going to be talking about this stuff. And I sort of was trying to think of some of the non-absurd mistakes that I made as a resident. And more importantly, it's the lack of a system in which one could make the mistakes. I think we just didn't know any better. It's only now I had the luxury of leaving medicine for many years before even coming back to it in a

sort of different capacity. So I don't think it was until I fully left that I realized, holy cow, that was the wild west, man. And we were doing our best. I mean, that was sort of, to me, one of the real beauties of being at Hopkins. In addition to, I mean, I chose Hopkins as the place I wanted to go because of John Cameron, who was the chair of surgery, Charlie O, Keith Lillema. It was basically three people who I had never met before I interviewed there was the reason I wanted to go. Great guys. So you had these three total legends, and then you had this idea of you were going to go to the epicenter of the surgical residency program. William Stuart Halstead

creates this program in the late 1800s, and there was this sort of lineage of what was going on. You're in this place that's in theory, the best place in the world. And yet on day one, I remember the responsibility I was given and I'm thinking, oh my God, am I good enough to do this? Am I? And the other thing that humbled me was the absolute faith that the patients had in us. And it really humbled me, really made me think, they think I'm better than I am. They completely trust me. And how do I balance communicating my own insecurity about even the most trivial thing? I'll give you a silly example. You're pre-opping a patient and you're putting an IV in them. And you're thinking to yourself, I'm not even that good at this yet. I mean, this patient is going to potentially get stuck three times while I fumble to put an IV in them because the anesthesiologist couldn't be here right now to

do it and I'm sort of filling in. And yet they're stoically sitting there thinking, well, I'm at Johns Hopkins. I think that's the nature of a teaching hospital. So that's part of what we're supposed to be doing. But when it starts to get to the really serious stuff, I think there were many times when certainly I felt like I was out of my lane. You realize you walk into this incredible lineage historically of public trust in the profession. And a patient you meet in the emergency room will trust you to put a knife to their skin within two seconds of meeting you, or the tell you

secrets they've never told their spouse of 30 years, just because you're the doc. And it's this incredible sort of awe inspiring, wow, they trust me more than I trust myself. I remember trying to put a central line into a difficult patient, you know, at 3am, the patient probably didn't even need the line, you know, we were putting central lines and everybody. I was putting central lines for people in the parking lot practically when I was an intern. I mean, you didn't want to have your chief resident walk in and say, why doesn't this patient have a central line and lose it? So you just put a central line in everybody on the service for fear of getting yelled at. It was just absurd, the things we used to do like that.

I remember one night I tried to put a central line, couldn't get it, and I signed it out to the other resident. And I said, I tried, I couldn't get it. I tried, I don't know, five, six times. And then he went to do it. And he said, I was able to get it. By the way, I think you tried more than five or six times. I said, what do you mean? He says, oh, there were 20 introducer holes in the neck area where you went in. And I thought, gosh, the patient was ventilated. They were intubated. I just had no idea how difficult it could be. And the mantra was you just try again and again until you get something right. That's the surgical mentality.

That's sort of the idea is that you will perfect it. And if it takes a million times, it takes a million times. Yeah. So what year did you start working on that book? I mean, you and I had spoken about some stories that even ended up in the book years before. So obviously, the idea had been with you for probably 10 years. But when did you actually like kind of put pen to paper and start saying, I'm going to do this thing? I remember telling my dad, who's a hematologist

or leukemia lymphoma expert, I remember telling him that I was seeing things in the hospital as a student and as a resident that were just mind-boggling. I couldn't really grasp with the collision of sociological issues to see us spend a million dollars rescuing a patient only to go out and have them repeat that behavior that brought them in, or a new medication finally get invented in the pharma world and brought to the bedside, but docs just didn't feel like giving it or weren't aware of it. And you thought, wow, the implementation science of medicine is more challenging than the discovery science. And if you can invent Kevlar, but people don't wear it, it's a failure of the delivery or implementation.

I thought this is where the opportunity is. And then I think, you know, part of things in my career were right time, right place, right? That's when everyone started to say, hey, wait a minute, we could deliver care better, safer, more reliably. But I told my dad these stories about stuff I was seeing. And there's this one patient who basically didn't want anything done. Sometimes as a resident, you connect with a patient at the bedside and you realize they really don't want

this surgery that they're going to have done. And you communicate that to your team. And you were great about communicating. You had no hesitations to say, this is what the patient believes, or I'm concerned about this. And hyper communicators do great in surgery. They do great in medical school. They do great in surgery. They're annoying in the real world. But in surgery, you want that nonstop communication. Are you going to the emergency room? Should I come with you? Are you going to get these lab tests? Where should I stand in the operating room? Those are the communicators we love. It's always amusing. I have every now and then a parent who will call and say, my son who's in high school wants to go to Hopkins Medical School. Can you help him or

talk to him? He has amazing hands. He was putting puzzles together at age two. It's like they're all learned techniques. There's no gifted hands. They're all learned techniques. And by the way, we're not going to help any one kid given preference in getting into med school. But you realize there was this, when I was a resident, there was this patient who just did not want surgery. And the doctors insisted that she have this invasive biopsy in order to figure out what the cancer type was. But the CAT scan essentially said it was clear what this cancer type was. And the biopsy was just to confirm it. And I remember the patient just- But regardless of that, she didn't want the surgery to remove it, period.

Yeah. Presumably she was old or- Yeah, she was old and she lived alone and she didn't want the biopsy, the invasive biopsy. She wouldn't want a surgery to remove it if the biopsy confirmed. So she was basically saying, I just want to go home and sort of live the last few weeks, months of my life in peace. Yes. Leave me alone. And I thought, well, maybe it's important to prognosticate to tell her you've got maybe two months or you've got six months. The reality is we never really know. Like we have any clue. Yeah, exactly. So I remember telling the

team she didn't want anything done. Well, we have to do the biopsy because we don't know what it is. I'm like, well, she doesn't care what it is. We have to get it. Well, why do we have to get it? To know. We have to know. And I'm just looking at this train that just will not stop and listen to patients. And I'm thinking, how did we get to this point where we just do stuff on people who don't want things done? And you look on a broad scale now, as I've been researching the cost crisis for this new book, The Price We Pay, healthcare is now the number one industry in the United States. It is the number one business as of January 2018. Entire cities have been transformed. I mean, look at Pittsburgh. It used to be a big steel town in my home state of Pennsylvania. You look around, it's all healthcare. All the tall buildings are healthcare, health insurance, health administration. And you realize, how did

we get to a point where we've created this train that sometimes doesn't listen to patients? And my dad said, write these stories down, Marty, because you'll be amazed how you forget when you go on. And someday you'll be teaching residents and students, and these are important things to remember. And that's when I started writing things down for the book Unaccountable. The TV show, The Resident, by the way, did a beautiful, and it brought a tear to my eye, they did a beautiful description of that case where that patient wanted nothing done. And the TV show, the patient simply said, I want to go home and clean the garage. I don't want to leave my wife with the mess I've accumulated over my lifetime.

It was beautiful. To me, that was the most amazing part of being a part of that show. Yeah. My mother-in-law is obsessed with that show and she didn't realize it was based on you and your book. And of course, for the listener, my mother-in-law, it was kind of a funny story here because she used to work for Charlie Yeoh, who was one of these legends that drew me to Hopkins. And so she was actually one of the first people I ever met at Hopkins because the day I showed up, I wanted to go and meet Charlie Yeoh. So I went up to the office like an eager literal intern with my tail between my legs. But she just had like a soft spot in her heart for me. And when she knew I was talking to you today, she just couldn't tell me as many times as how many times I needed to tell you how much she misses you and

how excited she was that I was talking to you. But anyway, it's her favorite show. For me to be able to say, you know, that's about Marty, right? She's like, what? Oh my God, no. And it went from being her favorite show to, I don't know, like a deity of TV or something. By the way, your mother-in-law Janet was wonderful. And one of the reasons why we mother-in-law, Janet, was wonderful. And one of the reasons why we all loved her so much as a resident was, here's a normal, caring person in the Department of Surgery. You can actually talk. They would listen.

It wasn't like, suck it up and move on. So here's like a normal, healthy, human ombudsman in the middle of Navy SEAL training. And it's like, oh my gosh, she'll hug us. And she had just feelings and she was kind. So we all loved her. But yeah, I try to lay low with the show because there's nothing really good that comes out of associating your name with a show like that when you have no editorial control. And even the first couple episodes, I learned in retrospect, there was a low budget. Now the show's crushing it and they'd spend four or five million dollars a show. But back then when it was a tight budget, they had, for example, an episode in the early parts

where a medical coder was rounding with the doctors in the CT scan room and telling doctors they need to order this test. And it's like, come on, no coders are rounding with us. And then over time in their budget and they got more people involved, they really beefed it up. And now it's really, it's a drama about the business of medicine, the TV show, The Resident, whereas previous medical dramas have been about sort of the medical side and medical care. So this is an attempt to really look at the business of medicine. When did you meet Peter Pronovost? Did you know Peter before you got to Hopkins? No, I met him. I met him in the ICU. He's an ICU doctor, as you know. And so I met him in the ICU. And's an ICU doctor, as you know. And so I met him in the ICU.

And then when you get on faculty at Johns Hopkins, they assign you an official mentor. So he was assigned as my mentor. And we had offices next to each other. And he started talking about, gosh, we're using this checklist in the ICU when we round to make sure we're covering all these points, like what day of antibiotics is this patient on? Let's anticipate where they're going to go after they leave here, and how can we make preparations? So that's where I got to know him.

Yeah, he was incredible. I always think back to my time at Hopkins as unbelievable. I just felt too lucky to be there, and I just couldn't believe everywhere you went, there was this person who was exceptional and arguably the best in the country, if not the world at what they did. And certainly Peter, there's no exception. Interesting as an aside, when I decided to leave medicine, a lot of people thought you were making the biggest mistake of your life. Peter was one of the few people. And by the way, the people who said that and felt that way did it out of complete compassion and concern. So nobody was nasty about it. But Peter, he gave me a book by Joseph Campbell and said,

read this. I think it will help. And he was the most understanding person about it. He was like, no, Peter, you know, I think you'll be a decent doctor, but if you choose to leave the practice of medicine, I completely support it and proud of you. And I've never forgotten that Peter was sort of the first person who kind of accepted my decision to leave. We were so torn, by the way, because we had these conversations when you were thinking about leaving. And I thought, gosh, you're so creative. This place beats creativity out of you, this cookie cutter job. So run with that creativity. But on the other hand, we loved working with you. It was like having a reliable, solid doc to work with is the best part of the job. So that's anyway.

Well, the good news is there were so many of those at Hopkins. I mean, I felt like my absence certainly didn't change anything because it was just, honestly, I felt like everybody there was, we joked about it. It was sort of like what it must have been like to play for the Yankees, right? Everywhere you look, there's like the best person at whatever they were doing. But how much resistance did you get from the field? Because I got to feel like writing that book ruffled some feathers. And again, you do a very good job in Unaccountable of not turning this

into a holier-than-thou crusade. You're self-deprecating. I mean, but nevertheless, in some ways, it's one of the first times an insider said with vulnerability, look, we're not perfect here. We're struggling and we don't have a system that's great. It wasn't some sensational whistleblowing nonsense. It was almost a cry for help. But we come from a culture, and this isn't just Hopkins, I think this is medicine, of a very stiff upper lip. You suck it up and you do it and you're doing the best you can because our intentions are good. I mean, I can only recall two residents in the entire time I was at Hopkins that were just bad people. And when you think about how many residents would come through that program,

that's less than 1%. So there's less than 1% of the residents I saw at Hopkins were just horrible human beings. So we got all these people who are good and they're trying to do the best they can. And there is this veil of secrecy. And you come along and you say, we're not doing good enough. Like we could be doing better. And I'm going to share with the outside world for the first time what this means. So did someone like sit you down and say, Marty, shut the hell up? I tried to make it very personal.

And like you say, I tried to point out where I've made a mistake in taking care of patients. I try hard to basically say, look, I'm a human being. We're all human beings. We're going to make human mistakes. Let's not blame the human being. Let's talk about how we minimize those mistakes, how we create safety nets when they do occur, and how we talk openly and honestly about them so that we don't go home with a little PTSD because it is a horrible feeling when you're involved in those things. But I tried to tell

my own story of observing in residency at an affiliate hospital, a woman walk into a place that was a branded breast cancer center. And it really wasn't. There was somebody there practicing outdated breast care. They didn't offer all the surgical options. They didn't offer any trials. And I just thought, this is dishonest to the patients. Now, what do you do with that observation? Do you internalize it? I remember telling my dad once about a surgeon who shouldn't have been operating.

And we've all seen them. They're everywhere. I mean, most surgeons do the right thing and always try to. And we don't want to create hysteria, but you do see this 5, 10, sometimes 15% of surgeons that should not be operating. And I told another doctor in the hospital about what I witnessed in the operating room and how it was an entirely avoidable and it was a skill issue. And the doctor just kind of put his head down and said, yeah, that's too bad. And I thought, is that how we help each other? Is that how we police ourselves?

There's got to be a better system. And at a certain point, you realize, OK, the state medical boards, it's not really a feasible way to help outliers. The departments, they're not always incentivized or driven. Generally, we respect everybody's autonomy. Hospitals are profiting from the individuals. Not that they want anything bad to happen, but they're just not financially aligned to really intervene. Typically,

I don't want to make a broad statement there, but no one is in nobody's direct interest. And so I realized we've got to educate patients on second opinions. We've got to educate patients on the questions to ask. And I try to be very honest about the issue. Now, the one problem with the book Unaccountable was the title. The publishers slapped their own titles on it. And I, of course, had a positive title on it. And they come back, no, we're going to call it Unaccountable and this subtitle. And of course, I'm thinking that's not going to fly well with the medical profession. It might sell more books. And they had title rights. And I've learned, I probably got burned on that title a fair bit because of the 10% of doctors that contacted me, most doctors said, thank you for speaking up, or I've seen this, or this is going

on here. But the 10% of doctors that gave me negative feedback, I'd say nobody of those doctors read the book. They actually just reacted to the title or the title of a book review. And the media sensationalizes the topic of patient safety. And it's very difficult as a patient safety researcher to treat the subject in a way that the media is fair and balanced. Because what they want to do is just, they're all in the ratings business. I remember Fox News wanted to do a one hour special on this topic and had me in it. And yes, doctor, this is important. We want to help this effort in patient safety. And then they call the show the night before it comes out, they call me and they say, the show's coming out tomorrow.

It's called Dr. Death or something like that or something. I'm like, come on. I thought you were going to treat this. And so that's the issue with patient safety researcher. To be very honest, I'm thankful that I'm no longer a researcher in patient safety and my entire research effort has moved on to the cost crisis in health care. Because during that era, a 10-year era, when we were doing a lot of research on patient safety, working on the surgical checklist. The media was sensationalizing the subject a lot. And the profession, to be honest, if somebody had a medical mistake, a patient was complaining, they were sort of relegated as crazies.

They were just kind of put out there. Any malpractice claim that was resolved had a gag rule that I wrote about in Unaccountable. So you could not speak to anyone for the rest of your life about your medical mistake. Well, mistakes happen. And gagging somebody is tragic because talking about the mistake is part of the therapy, not just for the patient, but for us docs. Well, I'm glad you said that because there are several things that I still feel upset about from residency. Again, they're not specifically directed towards any individual or even the program itself, but more the overall culture. And this is one of them. As

you probably recall, there was a very clear rule. Now, it obviously wasn't a written rule. It was an unwritten rule. But whenever there was an outcome that was not desirable, so that meant a patient died, even if there was no mistake involved or obvious mistake, but patients die. At Hopkins, doing the most complicated surgery that can be done on this planet, and because it's a huge tertiary center, you're getting people from all over the world who are coming with the biggest problems. Invariably, people are dying. Well, the rule was, the unwritten rule was, if there was even a chance there was going to be a lawsuit involved, you weren't permitted to speak with the family. And so, and I remember this very clear one night when I was an intern and I was in the WICU. So one of the ICUs at Hopkins, this patient had been on our service

for, patient had been in a hospital for probably three months. I was just coming off the end of being on one of the, so I actually, I wasn't the WICU resident. I was on one of the surgical teams, but you're taking care of the patient in the ICU. And one night I'm on call and this is kind of the end. I think the family withdrew support and this patient died. And so I'm filling out the death certificate and his wife comes up to me and it's two in the morning and she just wants to talk. I mean, she just wants, their kids aren't there yet. They're probably not going to be there till the morning or whatever. So I just talk with her. And again, there's no blaming. This is just a, she's questioning, oh my God, should we have even done this surgery? The gravity of this is starting to weigh in. It's a typical situation

of a patient who was probably in his late 70s who had an aggressive surgery for a cancer. And yeah, maybe in retrospect, it wasn't the right thing to do. Did anybody make a mistake there? No. Even if somebody made a mistake, it's remarkable how patients are forgiving. They just want honesty. They just want honesty. They're hungry for honesty. Absolutely. And so I remember kind of the next morning getting spanked a little bit by the chief resident when he found out, you were talking to Mrs. Smith for an hour last night. Like, how dare you? Right? Our job at this point is to make sure that if their lawyers call and want the medical records, we get them to them in a timely fashion. We cooperate. And I'm like, what the hell are you talking about? Why is that what we're thinking about at this point? And as myself being a victim of a medical mistake, which you wrote about actually in the book, I was amazed at how well you knew that story. I don't even, like, it's funny. I remember when you sent me the galley of that, I was like, I can't believe Marty remembers all

this stuff. Because I have total hippocampal wipeout from residency. I remember huge blind spots I have. But I never wanted to sue the surgeon who did this stuff to me. But I was definitely upset about the fact that he wouldn't talk to me. It was surgery gone bad, if you will. I feel like I may have told the story before, but I had a wrong side surgery. When the surgeon operated on the wrong side of my spine, something went wrong. I woke up from the surgery in worse shape than when I went in. And for three weeks, he refused to acknowledge anything was wrong. I was seeing him in clinic. He actually called me a pussy and told me to suck it up. He was a horrible human being. There's no question about that. Not because of this. He just,

this guy was a horrible human being who happened to do this. But what amazed me was the complete and utter lack of honesty. I mean, just, and to this day, people say to me, how did you not sue him, sue the hospital? And I said, look, maybe it's because I'm Canadian and we're just not litigious people, but it was never about that. This wasn't something a dollar was going to solve for me. I just wanted a guy to be able to say, oh my God, Peter, I can't believe in all. And I understand how the mistake happened. It was VIP treatment. That's the problem. So I'm a medical student at Stanford. I've got this huge finding on the MRI. They want to get me right to the OR. It's a Sunday night. We're going to pre-op you first thing in the morning. You're going straight away. Didn't even meet the surgeon, no physical exam. It was a perfect and colossal mistake that was the result of a whole bunch of people trying to do the right thing as quickly as possible. And in all of the hoopla, they got

the side wrong. Yeah. It's always the case with VIP care, isn't it? If you're a VIP, do not tell anybody. Yeah, exactly. Do not get VIP care. Do not say you're on the board or have a buddy who's a doctor on your average Joe walking in and ask all the right questions. Yeah. But you went through, I mean, that was a lot, but people are just hungry for honesty. And you know, unfortunately now the risk managers of hospitals have dominated the practice of medicine. When things go wrong, they basically create this deny and defend mentality. So you're saying that's gotten even worse? It's got, well, I personally think that hospitals are making too many decisions based on what the

risk managers are telling them to do. Because from a risk management standpoint, legally, and this is with any corporation, it's not just medical, you want to basically shut off communication, deny and defend, hold your party line, and fight it in court and in the settlement process and depositions. But in medicine, people want honesty. They're forgiving. And they want to understand what happened. And it's remarkable.

I had a patient once who said the surgeon wasn't able to do this in the surgery. And they sent the patient here to Hopkins. And I said, well, yeah, I'm sorry you went through that. Yeah, us too. But you know what? Our surgeon did his best, and he offered for us to come here initially to Hopkins. And we said, no, we'd really want to stay here in North Carolina. We'd like you to go ahead if you feel comfortable. And there was so much honesty, you realize people don't really sue because things go bad. They sue because things go bad and there's no honesty and transparency. Well, and I think there are data to support that because I remember in residency getting kind of

annoyed by this situation of when bad things happen, you're not allowed to talk to the family. And I remember pulling out some, this was soft research, but the takeaway seemed very clear to me, which was lawsuits happen when communication breaks down independent of the severity of the outcome. So you can have lawsuits over bad communication when the outcome was not really that bad. You order the wrong diagnostic test on a patient, for example, they're not hurt from it. They were exposed to maybe more radiation than they should have been, and that's bad. But that's different than you operated on the wrong carotid artery. But it seemed that the lawsuits, the severity of any sort of litigious behavior, was much more proportionate to everything that happened after the breach. I mean, again, that was my very kludgy takeaway 15, 20 years ago. Is that still,

did the data bear that out? Yeah, well, the studies show that satisfaction of the patient is the bigger driver rather than the actual event. So if the patient is extremely satisfied, the risk of a lawsuit is low. And that's why I tell docs, when something goes wrong, reach out to the patient immediately and disclose. I had a patient where I ordered a CAT scan and they shouldn't have had a CAT scan. I remember you told the story once and this patient didn't like you in the first place. The patient was already pissed at me. The patient had a pancreatic leak, which is 20, 30% of all pancreatic surgery. They struggle with a leak that keeps them in the hospital longer. They feel sick afterwards. And I basically went to this patient thinking, gosh, this guy's going

to sue me. He had a similar name to another patient. And when I talked to the resident who then talked to the clerk at the nurse's station, something broke down. I might have not been clear. I might have said the wrong name. I don't remember. I was busy. The resident might have passed the wrong name. The clerk may have entered the wrong name. Who knows? We're not going to have an investigation. But I went to the patient and I said, look, I made a mistake here. Something went wrong. I take responsibility. You shouldn't have had that CAT scan.

It was not intended for you. It was intended for another patient on this floor. I mean, this is the stuff risk managers just vomit when they're here. Right. They're like, shut up. Come up with an excuse. Because it's plausible that you would do a CT scan on a patient with a pancreatic leak. You could have easily gone in there and said, Mr. Smith,

I just wanted to be doubly sure that the leak was contained. So the guy looked at me and I said, I'm happy to get the results right now. As soon as I found out about it, I came up here to tell you. I'm happy to go down and get the results right now. I haven't seen the results yet and share them with you. We can just see what the CAT scan showed. This guy, he already had sort of an angry look on his face. He was already upset. I think idealistic expectations of how his recovery should have gone. And he looked at me and this guy put a big smile on his face.

And he said, Doc, thank you for coming up here and explaining this to me. I really appreciate your honesty about it. That guy never sued me, okay? We are Facebook friends today because he just hit me. People are hungry for honesty in medicine. Now, honestly, when you make a mistake and someone dies, you need to talk about it. I mean, I hear every now and then about a tragic, horrible, avoidable case. And my first reaction is, I want to talk to that cardiology fellow or whoever was involved and let them know this happens to all of us. We're human beings. Things are going to happen. Let's talk about how to prevent it. How do you feel about this? We've

got to talk through, because I'll tell you, when we internalize, it's bad for our bedside skills. We turn into robots. I don't know if you saw the movie Hurt Locker, where this guy's diffusing bombs in the Middle East. Then he comes home and his wife is telling him, go pick up some cereal in the supermarket. And he's just looking at these cereals like, what's this matter? I'm in a war overseas and who cares what cereal? He can't do the activities of normal living. American sniper, same thing. He's a hero in war. And then he comes home and he's watching his kid in daycare.

His wife's trying to engage with him. And he's just a robot. And that is exactly what we doctors go through when you're in the ICU. You're in the trauma bay and somebody has a tragic illness. And you're yelling and screaming to get a in the trauma bay, and somebody has a tragic illness, and you're yelling and screaming to get a chest tube in, and you go home, unless we address it head on, unless we talk about it, unless we can't cope. And the way we tend to cope is we just internalize it. I'm always laughing when one of my friends says, I went on a date with a doctor, and

he didn't have any emotions. And he just started talking about different incisions he would use on the scalp to approach a brain tumor. And I'm like, we internalize too much at the hospital. And it's important to have these honest conversations. And by the way, this is what I love about the students. The students have very little tolerance for BS. I guess it's just part of this millennial generation. So when they see stuff in the hospital, they call it out.

Wait a minute. This lady didn't want a biopsy. Why are we doing the biopsy? Ho, ho, wait a minute. They don't care about how it's going to affect them. It's very different from us. As students, we were head down. When someone says jump, we say, ho, hi. You fall in line. I mean, do you remember the twist, which was this pastry on the tray, on the catering tray at M&M conference at Hopkins for many years. Yeah. Yeah. That was the NAFLD T2D special. Right. Exactly. But the word was John Cameron, the chief of surgery loved the twist. And there's only one twist on the tray. If any resident or med student took it, it was like the biggest faux pas. You do not touch the twist. And they would literally orient you like, here's how you call the blood bank.

Here's where you send the labs in. And don't touch the twist at M&M conference. Like part of the four things they tell you when they start orient the students. And I heard one day, I wasn't there, but I heard one day they found a student who showed up early for conference and he was halfway through the twist. And they were like, what are you doing? No. We've got to get another twist sent up here immediately.

A twist emergency. They're trying to do like the Heimlich on him and preserve the remaining piece of the twist and make a clean cut and prepare their apologies. I mean, like you're saying, we just fell in line. It was the military. And gosh, I remember patients struggling in the ICU. Their oxygen saturations were low, but it was 627, and it took me three minutes to walk to the M&M conference, and you were never late for that conference. And I'm literally like, nurse, can you just manage? I have to go. I have to. This

is absurd. These patients struggling in the ICU with this incredible, I've never seen anyone show up late to that conference in my 16 years of conference at Hopkins. And it's just amazing, this militaristic. And the reality is we should be at the vet, whatever the patients need, we should be there for them. But there's this culture and it's changing. So I love the students. The students are the most exciting part of the job. They are, with the pricing failures that we're writing about now in our research, they are going after these predatory billing practices. And they're saying, excuse me, what the hell? You billed a patient $10,000 for a CAT scan.

And they've started this movement called Restoring Medicine. They've got a Facebook group. They've got a website. These are medical students at Hopkins? Yeah, medical students at Hopkins and around the country. They're just trying to get a grassroots thing going. They did this on their own. They approached me and they said, look, we love the book, The Price We Pay. We want to work on this. These are our patients that are getting harassed for their medical bills. The patients did not come to the hospital administration

or billing department for medical care. They came to us, the doc, not come to the hospital administration or billing department for medical care. They came to us, the doc, and now they're getting shaken down with these egregious, overpriced, surprise bills. It may be that this is going to be the number one issue in the next election. There's some early polling from the LA Times that are showing it's not just healthcare that's the number one issue in America at the voting polls. It's medical bills. In the midterm elections, Trump's first term, in the midterms, health care surprised everybody. It was the number one issue. They didn't think it was going to be that high. That was not the Obamacare debate. That was people getting hammered with medical bills. And the students right now are saying enough is enough. That generation demands transparency in

every aspect of life. There's so much I want to talk about on this front because that's the subject of your book and the stories that you tell in that book just they really resonate with me. But I want to tell a funny story just because you brought up John Cameron and he is such a god to me. As you pointed out, the Hopkins medical students are probably the best medical students in the country. And so that was sort of one of the privileges of being a resident there was for the listener, there's a real hierarchy in medicine. So you have the attending, that's the faculty member, you have the fellow. So they've finished their residency, but they're now doing some additional training. You have the chief resident, who's the most senior resident. So they're still in training. You have sort of

mid-level resident, junior resident, intern, sub-intern, which is still a medical student, but in their final year, and then the third year medical student. I mean, that's basically the entire hierarchy. So one of the real privileges of being at Hopkins was even as an intern, you got to scrub in with Dr. Cameron when he was doing a Whipple procedure. You got to retract and you got to remove the gallbladder. You have the privilege of being yelled at if you're really lucky. Well, I mean, it's funny because if you were in the general surgery categorical program, you couldn't wait to get in there and do that. Now, of course, if you were one of the neurosurgery

residents, that might not be as appealing because you're like, oh my God, you know, I just got to get through this thing. But, but I loved it. So anytime I got to be in the OR with Dr. Yeo, Dr. Cameron, it was like the greatest day of my life. And I didn't care if I got yelled at a hundred thousand times. And I didn't care if I got yelled at 100,000 times. And I didn't care if my fingers went numb trying to retract the liver. It was the best. And there was generally a medical student in there as well. And again, if the medical student wants to go into surgery,

it's just going to be a fun afternoon if they're competent because they're going to get pimped. So I don't know if the word pimping is still, is that still legal? Oh, yeah. Pimping is alive and well. Okay. Okay. Can you explain what pimping is? It's the Socratic method of teaching. It's really posing a question. And so it's just a method of explaining things, but the students perceive they've been taking tests their entire life,

on average, every four days of a human being's existence before they come into medical school, they've been taking a test. So they perceive it as, oh my gosh, the great John Cameron or whoever the surgeon is, yo, Lillimo, is asking me a test question. And I'm cataloging through the billions of things I've memorized to see if I know the answer. And if I do, I will make it. And if I don't, I'm dead. We're more interested in someone's communication skills, honesty, affability than we are if they know every fact. And some of this stuff is not knowable. Anyway, pimping is alive and well. So the term still exists because it was a very important part of what was happening. And you thought a lot about this. You knew any day you went in the OR, okay, what are they going to pimp me on? Is it going to be the anatomy? Is it going to be the

history of this surgery? Is it going to be what the next step is? That kind of thing. I personally don't do it after somebody passed out when I asked them a question once. Normally they're shaking as you're asking them a question and you need their hands to be steady. So I basically ask myself the question. If I were to ask myself so-and-so, I would think it's Sonya White. Well, I'll tell you, I thought there were some attendings who pimped purely from the standpoint of just trying to torture. Cameron was not one of them. No. And Cameron, I actually talked about this with Ted Schaefer on my interview with him.

Cameron did this thing called Sunday School with his interns every morning. It's like 7 o'clock every Sunday morning. We did Sunday School with Cameron where we would have these discussions about the history of surgery. And for those of us who came to Hopkins with that sort of love, this was a gift from God. Like, you couldn't imagine you were getting to sit down with the most famous surgeon in the country and one of the greatest historians of surgery and get this lesson. So to be in the OR with him was usually a history lesson. Okay. So fast forward, I'm an intern on GI Gold, which was

the flagship service at Hopkins. And we had a medical student. You always have two medical students. And as I said, usually the medical students at Hopkins, because they're just so good that it's fun to have them around, even if they don't want to go into surgery. They're just good students. And you get to know them and stuff. So I became friends with many of the students. And in this particular month, one of the students wanted to go into neurosurgery.

Well, she's at the right place. We're at Hopkins. But you knew deep down that it wasn't going to happen. She just was a space cadet. Like there's just no other way to describe it. She was out to lunch, actually. The problem is she didn't know it. She had this incredible confidence about her that did not match her ability. That's the most dangerous subtype. It really is. So we're in the OR one day and Dr. Cameron is always talking to the medical student. He's always being friendly. And he says, I do

remember her name, but I won't use it. So let's pretend her name is Susie. He's like, Susie, what are you interested in? And again, this is where any medical student will say, oh, I'm interested in pediatrics. Great. And he will march down the path of, do you know who the first pediatrician was? Blah, blah, blah, blah, blah. And he's just walking you down the path. And so Susie says, I'm interested in neurosurgery. And he's like, great. Do you know who the first neurosurgeon was at Johns Hopkins? And she's like, no. Now the listener, if someone's listening to this, they're thinking, oh my God, how would you know that? But here's the deal. If you're at Hopkins, you know this stuff. Just as you know, William Osler and William Stuart Halstead, who they were

like, everybody knows who created neurosurgery. It was a guy named Harvey Cushing. And he trained under Halstead in the late 1800s before moving to Boston and basically creating the field of modern neurosurgery. Yeah, the Cushing reflex. Right. If you're listening to this and you're not in medicine, you'd be like, why should she have known this? But if you're in medicine, you realize you can't be at Hopkins and not know this. Okay.

So she doesn't know the answer. So he keeps trying to give her a hint. He's like, well, he trained at Hopkins under Halstead in the 1880s. No, I don't know. He then went up to Boston and created this pro... No, I don't know. And by the way, at the time, Dr. Cameron is holding the bovie, which is, this is called the electrocautery, but everyone just calls it a bovie. And this is a device that revolutionized surgery. It's hard to imagine you could do surgery without electrocautery. So this is a device that cuts and simultaneously cauterizes. So almost everything we're doing in surgery is using this device.

And it was invented by, of course, Cushing. And so as he's holding the bovie, and he's starting to get a little irked now that she doesn't even have a clue. And he says, he invented the device I'm holding in, and he rattles off whatever year it was, 1907. No idea. No idea. He must have rattled off 10 other hints. She finally blurts out her best answer. Ben Carson, who at the time was a pediatric neurosurgeon at Hopkins, who of course has since gone on to become involved in politics. And he loses it. He's like, I suggest you learn your history of neurosurgery. Right. And I couldn't wait to get out of the OR that day to tell my other co-intern this story.

And this is how deprived you are of any sense of whatever. We thought this was so funny that we spent the next few months referring to Ben Carson as Benjamin Beauvoyer du Carson because we came up with this idea that Ben Carson had actually invented the bovie and that's why it took his name. But we had to come up with this whole French twist to make Beauvoyer. So 20 of the residents at Hopkins heard this story and we were all going on about how Benjamin Beauvoyer du Corson created the bovie and it wasn't Cushing and all of this other stuff. And to me, that's just an example. Like, I don't even know why I told that story other than it's just, you're so

sleep deprived. You're so giddy. You're under so much stress that you have to latch onto the dumbest thing as something that's funny. Yeah, absolutely. And it's like whatever it takes to appease the higher ups. The sort of deep sarcasm, I've been the subject of it many times with Dr. Cameron. I have a very good, strong, complicated relationship with the man. He's my senior partner. We've shared a secretary and a practice now for my entire career since I was a fellow under him. And he's both my best friend. I play golf with him maybe every other week. We're great friends. We've done

vacations together. The man's 82 years old and a legend in the field. And at the same time, he's my greatest adversary in some of the innovation I've been trying to do at Hopkins, mainly introduce minimally invasive pancreatic surgery. Now, he's been very supportive at times. At other times, he'll look at me with the suspicion of, are you using those toys again? Heaven forbid we have a single complication, even though the baseline complication rate from pancreas surgery is 20%. It's unavoidable if you do a fair amount.

If I have one complication and we had, did you use those sticks and toys and cameras? Yes, Dr. Cameron, we use the minimally invasive to have less surgical stress on the patient's physiology and nearly eliminate the risk of a wound infection and other complications. And he will say, well, next time you might as well just take that patient and roll them into an empty elevator shaft, you know. Or he'll call you an assassin or what was the other one he used to say? Marty, M&M conference. Sometimes I wonder, whose team are you on?

The patients or the cancers? We'd be like, no, Doug Cameron. The gas does not spread the cancer, inflating the CO2 gas. And that was an old criticism that I've answered thousands of questions about. I heard the gas spreads the cancer. No, that's not true. It's like lunar eclipse can spread the cancer. I do want to go back to something else you've said.

We sort of glossed over it. But before we get on to the sort of price stuff, which is, it's so frustrating to me. Two things. One is, you're absolutely correct. And I've never really thought of it as explicitly as you've described it. But the idea that the doctors, nurses, and healthcare providers who are involved in seeing bad outcomes, it's a form of PTSD. bad outcomes, it's a form of PTSD. Now it's absolutely not as severe as a person whose job it is to diffuse roadside bombs. And I don't think that anything we would ever see in the

hospital on our worst day comes close to what you're going to see in the battlefield, but it is still PTSD. Yeah. And you bring it home. And I think of all of the weird rituals I used to have. And I don't think, I mean, I maybe told this story once, but we saw a lot of gunshot wounds and sometimes the patients die in the field. So you never see them. And then sometimes they come in and you'd get to do these heroic things and they, you save them. But there's a subset who die in the trauma bay. There's quite a few of them. And I don't know why, but I couldn't sort of let that go. And I remember distinctly one case of this guy who

looked like he was about 25, single gunshot wound to the head, but he must've had some vital signs in the field. So he was still brought in the trauma bay. And I might've actually been the intern at this point. I don't think I was the Halstead chief. So we're doing the few things that we can do to basically try to at least see if he has some vital signs so we can do something. And, but very quickly, it's clear that nothing's going to happen. So we don't even bother to call neurosurgery. I think at this point, he's just declared dead. And at this point, everybody just has to sort of leave the trauma bay quickly so that the cleaning staff can come in, body can be put into a bag, get all the blood

off the floor, open the trauma bay up for the next one. And his wallet is on the floor and nobody else is in there except one of the nurses. And I pick up the wallet and I open it up and there's his driver's license. And I look at the picture and you can see what he looks like when he doesn't have a gunshot wound in his head. Looks good, I bet. Yeah. Then there's a picture of a girl in his wallet and she looks like she's about three years old. And I'm guessing it's his daughter. And I'm thinking to myself, I realize this guy is involved in something to do with drugs because 95% of the trauma we saw was drug related. And it's so easy to just dismiss that as, well, now that's what's going to happen. If you're going to sell and buy drugs in the streets

of Baltimore, you're going to get shot once in a while. And I have no attachment to this, but I looked at that. I look over at him and his brain is coming drugs in the streets of Baltimore, you're going to get shot once in a while. And I have no attachment to this. But I looked at that. I look over at him and his brain is coming out of the side of his head. And that's unfortunately just the reality of what a gunshot wound to the head looks like. And I'm looking at this picture and I'm just torn up by it because I'm thinking, this is one more kid that doesn't have a dad. Whatever this guy did, he didn't deserve this. Whether he stole something or didn't pay somebody or whatever he did, this was too extreme a punishment.

But then I also realized like whoever did this to him is also in the same situation. This is just one horrible situation. And it just killed me. It's hard to explain how upset I was about this. But I also realized you have about 10 seconds to get your stuff together and get on to the next one because you're going to get paged again and again and again. And oh, by the way, you've got seven other things you didn't do yet on your list today that you have to go and do. And you've got to go track down those blood culture results. There just wasn't a moment to stop and do this. And I thought to myself,

we saw so much trauma. And I don't mean just trauma literally as in trauma, but I mean things that are traumatic to a human. And yet I don't once remember there being a discussion about that and how one should deal with that. And I do think that so much of the burnout that we see, and my friend ZDogg, who I know you've met briefly, but hilarious. Yeah. You guys should spend a lot of time together. ZDogg, who I know you've met briefly, but hilarious. Yeah. You guys should spend a lot of time together. He's spoken about this so eloquently, but this idea of physician burnout, he calls it sort of mortal wounding. And I think he's right. This isn't, I'm tired of my job. It's, I don't know how to internalize what I'm seeing. And we're just, I don't think as a society, whether it be in the military or in medicine or in any field, we're just not, I don't think as a society, whether it be in the military or in medicine

or in any field, we're just not, I don't know, we're not coached. We're not encouraged. We're not taught how to share that. It would never make sense to me to talk to that, to talk with anybody else about that, including my peers. Because why would I bother you with that story? Because you got 10 of the same story. And you never think that, well, maybe there's value in talking about that.

And by the way, acknowledging how much it tears you up. Yeah. And it's exhausting to allow your emotions to go there and think about that patient's daughter and what's happening with the family. And should I reach out to a family member? You know, there's a nurse saying at the nurse's station, we have the family on the line. And you're thinking, I don't want to take that call

because it's emotionally exhausting and you're already exhausted. You haven't slept for the love of humanity in 36 hours. You got to prepare for the next one. So as a coping mechanism, by default, without any outside instruction, a human being in that situation will naturally turn into a robot. You just become androgynous.

You do not express any emotions. You basically say, this is part of the job and I've got to move on. But what happens is it changes who we are. And you see these incredibly bright, young people interviewed for med school, the sort of kid in college that says, when everyone's talking about their careers, I'm kind of thinking about med school. They're different from their peers, right? There's this intense sense of compassion, a desire to apply science to help people. It's a compassion-driven profession. The sort of person in high school says, you know, I'm thinking about nursing. They're different from their peers. We're all driven to medicine because of a sense of compassion.

And then you take these students when they interview for medical school at Johns Hopkins, and we ask them the standard question everybody gets asked in every medical school interview, why do you want to be a doctor? Because I really want to help people. And 90% of people will say they want to go into medicine to become a missionary doctor or to help the poor or underserved in some capacity, if not full-time, as part of their job as a part-time co-career. I didn't realize it was that high. 90% of people starting out have some desire to serve underserved, underprivileged people in some capacity. Exactly. They're not coming in

saying, I want to be an orthopedic knee surgeon. And we need good orthopedic knee surgeons, but they come in. Which you can still do in an underserved capacity. It was basically less than 10% of people have a very clear sense in their mind that they want to do the most elite or whatever thing. Yeah, they're coming in open-minded. They want to do some good. I mean, especially nowadays, the millennials are coming in with this social justice mentality. I mean, especially nowadays, the millennials are coming in with this social justice mentality. I mean, when you interviewed for med school, I said it. Let me ask you, how did you answer that question? Did you have?

I don't know that I was asked that explicitly. When I went to medical school, I wanted to be a pediatric oncologist. And I had been sort of very moved by an experience that I had seen of a child dying of leukemia, whose name I still remember when I was in college. It's funny. It's a funny story, actually. I interviewed with a surgeon at Stanford, an ENT surgeon, and you sort of get this random draw. Like you get a medical student that's going to interview you in three faculty. And I don't remember who the other two faculty were, but this one guy interviewed me. He was sort of a big

shot ENT surgeon. And when he went down this path of what do you want to do? And I said, pediatric oncology, he spent the entire interview trying to talk me out of it. Classic. He's like, what? What are you talking about? Do you have any idea how hard that is? I mean, are you crazy? Like, are you a glutton for punishment?

You want to watch kids die of cancer? Let me tell you something, kid. You do not want to do that. All right. You want to be a surgeon. You want to. And he just rattled off all these other things you would do. But you do not, under any circumstance, want to go into pediatric oncology.

And I was like, OK, all right. It's impressive. I mean, first of all, that is probably the most admirable area of medicine people can go into. I think pediatrics and psychiatry are probably the most impressive and honorable subfields of medicine people go into. psychiatry are probably the most impressive and honorable subfields of medicine people go into. And of that, say, cancer care and children, it's just, I really admire those folks.

But there is something to be said for what he pointed out that I couldn't appreciate at the time. And so as much as I can mock that story, when you don't have kids, there's something you're missing in that equation. I couldn't do pediatric oncology today if my life depended on it, because I think as a doctor, you're sort of always putting yourself a little bit in that person's shoes that's sitting across from you. That's what empathy means. And if we're doing our job correctly, we have to have empathy. So you have to be able to look at the world through their lens. The problem is once you have children, you look at the parent of someone whose child you're taking care of who has cancer. And I don't think I could do – I mean, now that I have kids, there are a lot of things I could take in life. But losing a child, I don't think I could take.

And so maybe he probably had kids. And maybe he understood without being able to articulate why. Maybe he understood, are you crazy? It takes a superhuman to do anything in that space. And I remember my time in this sort of pediatric oncology world. As you said, it's a very special nurse, respiratory therapist, physical therapist, physician, everyone who was involved in that care. That's a different cloth those people are cut from. Yeah, it's very impressive. We take people when they come in with these very altruistic goals in life, and

you look at them fast forward eight or 10 years later, and they're like different people. They are, all of a sudden, we beat them down. We make them memorize and regurgitate the urea cycle and the Krebs cycle 18 times, even though no one's ever needed to know the intermediary of the Krebs cycle on the fly in the hospital, right? It's just this absurd, this entire medical education is just so absurd. And I loved in the Price We Pay book, highlighting what's happening now with some of the innovative education, Jefferson, for example, the dean there saying, we're going to hire based on empathy and compassion and self-awareness. And yeah, we'll teach you what you need to know. You'll know the vocabulary.

We're going to teach you the life skills that you need to know. We're going to teach you how to communicate, how to find knowledge when you don't know it, how to be honest and say, I don't know, and you need to say that. So I love learning about this new approach to education. But there's this thing that we've been doing where we take these highly creative and talented, altruistic people. I mean, they look beautiful when they're in the lobby of the Ross building waiting for their interview. Their hair is combed perfectly. They're wearing these suits or dresses that are just dressed to the nine. And they say all the things that show that they are 100% in to help people.

They're mega athletes. They've run immunization programs in Nicaragua, right? They're the most creative, beautiful, awesome souls in the world. And they come in, and then we beat them down with this urea cycle, Krebs cycle, regurgitation treadmill. And in residency, don't ask questions and internalize all this crap that you're going to see. That's stuff that isn't right. Is this still happening though? Oh, it's happening. I mean, I was just talking to one of our medical students about it and they

were talking about how a lot of it's the accreditation boards and the examiners. These are not your millennials writing the boards. These are folks saying you have to know how to refract somebody for glasses, even though you're becoming a urologist. It's important information for you to know. Ophthalmology, it's just territorial. So they come out and eight to 10 years later, look at them. Their hair's all messed up. They're wearing pajamas. They don't have a business card. If you ask them, where's your office? They say, I don't know. They feel humiliated, belittled, subjected to all this beating. And we wonder why they feel entitled. And we wonder why they feel, why they're doing stuff they know they shouldn't be doing. We wonder why a doctor in a primary care clinic is giving out antibiotics too frequently. Or 10 years ago, we prescribed,

as physicians in the United States, 2.4 billion prescriptions. Last year, it had hit 5.4 billion. Did disease double in the last 10 years? No. We have a crisis of appropriateness. To memorize everything in medicine, it's pairs, diagnosis, treatment, diagnosis, treatment. That's the only way you can memorize the thousands of things we have to regurgitate. So you develop these reflexes. Gout is a condition where the big toe has pain at the joint from crystals. You treat it with colchicine. And you memorize these pairs. And what you lose is the sense of the threshold of treatment or the appropriateness of care. What comes out are these doctors that are entitled sometimes, burnout, we've beat them down, they're speaking a different language that has its own value system. Now,

this is not everybody. I mean, this is the sort of risk or the hazard along the path. To me, I think of the exceptions. I think of Chris Sonnenday. He's, to me, one of the most special residents I ever knew. I don't know. I always looked at Chris and thought, and Chris, by the way, he's now running the transplant program at the University of Michigan. But there was just something about that guy.

Yeah, emotionally vulnerable. Yeah, and maintained his humanity under any circumstance. And always, I guess I've never met a human in the context of medicine and I've met some amazing people, but it's hard to say like you've met one person who took everything that you would want to be able to do to the highest level. Yeah. So I always wonder why couldn't everybody, myself included, that is, be like Chris. I mean, it's hard. I mean, you're one of the most disciplined people I've ever known in my life, but it's hard not to get beaten down. Oh man, I was so jaded. That's the beauty of someone like Chris. And you never really got jaded either. I mean,

you were also in this group of people who just never, because you pointed this out yesterday when we were having dinner, it came up. It's like most of us, when we become jaded, become sarcastic. Most of us, when we become jaded, become sarcastic. That became our coping tool of, we just became sort of snarky, sarcastic bastards. Coping tool. Yeah. Coping tool. I mean, I remember my first day in the clinics in medical school, I was assigned a primary care office.

And I was working with a doc who's an internal medicine doc. I show up a little early and he says, the charts are in the door. Here's the schedule. Feel free to just go in and see the patient. And I go in to see the first patient at eight o'clock and there's a 15 minute slot and they're getting into all these deep issues and they're asking me about medication interactions. And I'm thinking, I think there's an interaction there. I got to look it up. And basically I leave the patient with, I'm going to get back to you. There's a lot of stuff here to unpack.

And then I go to the next patient at 8.15. And then the next patient at 8.30. And four patients in the hour. And each one, I feel like I gave kind of a half bait. And it's like, this is insane. And I stopped at 9 o'clock. And I looked at the head doctor. And I said, I know I'm giving you brief presentations here for a minute.

You're going in for a minute. And then we're treatment plan and a minute of documenting. And I get 10 minutes with the. By the way, are we going like this till five o'clock? Because like I'm dead. We're an hour into this. And this is crazy. He's like, oh, yeah, yeah.

And you do this every day? He's like, well, I do it four days a week. And I have an administrative day. Like, how are you not going bananas? How do you possibly manage this? He's like, well, you know, you get comfortable with certain diagnoses. The reality is, show me somebody in America today who's practicing office-based high volume medicine who's not burnout. I mean, it's probably, I don't know, 20, 30%. But you talk to folks, I was talking to an editor of the New England Journal of Medicine at the Brigham when

I was visiting. And we met and she said, I just came back from clinic, endocrinology clinic. And I said, Oh, how was it? And she's like, I only do it one day every two weeks or something, because I'm working for the New England Journal of Medicine. But it's clear to me, everybody there is burnout. I'm like, how could you not be burnout with office-based medicine? I mean, what's the solution to this? We have a population that seems to be getting sicker, and that's not medicine's fault.

There's lots of blame you could point at maybe why we're getting sicker, but there's no doubt about it. I mean, people are getting more and more sick with chronic diseases, and they're going to come to the healthcare system to get cared for. Again, I don't have the insight you do into what those volumes look like and to how many of those patients are being treated as outpatients and things like that,

but how do we take care of people? How is there enough time in the day to have enough doctors to take care of these folks? Because what you described sounds horrible. Like I can't imagine if I only had 15 minutes to see a patient. Like I get angry at my office staff if they give me less than two hour blocks between patients. Like once in a while they'll stack them one hour apart and I'll get upset. I'll be like, guys, are you joking? We have to spend the first 30 minutes just catching up before we even talk about the lab. So what you're describing seems so foreign to me, but at the same time, I'm empathetic because I realized that's the nature of patient volume.

So how does one fix this? By the way, it's horrible on both ends. Patients don't like it either. What I've discovered is doctors were able, so first of all, I personally believe that doctors are not lazy people. We just don't want to spend our time on things that don't matter. And there's an incredible amount of shit that's just been thrown at doctors in the last several years that has nothing to do with patient care. And I know you've talked about some of that in some of your other episodes. But the most exciting thing, and I'll tell you, in writing about these issues,

be it medical education or pricing failures or overtreatment or primary care, in the book, The Price We Pay, one thing I wanted to do is balance every problem with a solution or exciting disruptor. Because right now, I am so optimistic and up on the future of healthcare. So many cool things are happening. They're mostly young folks, mostly people that have very little tolerance for BS. The globally capitated primary care clinics are freaking awesome. Okay, so let's explain to people what all of those words mean and start with what does capitated mean? So basically, there's no billing going on because globally capitated means that the clinic as a whole, the organization is getting paid a lump sum amount of money.

So they don't have to worry about billing for every little thing. And they can spend as much time as they want with patients because they are evaluated by the outcomes of those patients long term. What percent of their patients use an emergency room multiple times or get readmitted to a hospital after discharge or the rates of certain health complications in a population long term. There's an exciting one in Florida called ChenMed. And the Chen family is an incredible group of doctors, a father and two sons, both of whom are primary care physicians. And they have made a deal with insurance and employers where they've said, look, pay us a

lump sum for the entire journey of care of your beneficiaries, your population, your employees, and we will assume the downstream risk. And if you do enough, if you have enough patients, you can assume that risk. So if your patient goes on to surgery, it's sort of counted, that money is sort of counted against the amount that you've been allocated for that patient. So what it's done is it's created this incredible incentive because the primary care physician assumes and takes the downstream financial burden of the care. It creates this incredible alignment of incentives long-term to do what's in the best interest of the patient. And docs know what's in the best interest of

their patient. It's exactly what you're doing. It's spending time. It's being able to go to the home or send somebody to the home. And they hire these patient navigators. At least IORIC does this. And the navigators will visit the home to figure out why aren't they taking their medications or what's in their refrigerator or what do they want to talk about or what's their activity challenge here? But this is different. The only example that people would think of today on a massive scale of capitation would be Kaiser Permanente, if you're on the West Coast. Is there any other large capitated system in the country? I'm a big fan of Oak Street, Iora, ChenMed. There's the Magento Clinics. These are smaller. They're probably doing much more than what one of these huge cap systems are doing, right?

Exactly. Is there a critical mass at which, from an actuarial standpoint, to manage risk, you have to have a certain number of patients in a pool to justify what, for example, the Chen family are doing? Because if I'm putting my sort of risk mitigation hat on, that's a dangerous proposition for the physician. They could get wiped out. If you have a small enough pool, one bad outcome, which can be entirely out of your hands, patients walking down the street, they get hit by a car or patient gets cancer. I mean, this is going to happen despite all of your best efforts in prevention. If that counts against your cap, you're done. So what's the number? Do you need like a thousand patients at a minimum to be able to... 500 has been the number that's been floated out there in the actuarial science for when it's worthwhile to self-fund a population. So in other words, if you're Apple and you've got giant cash

reserves, why do you need insurance? I mean, you can just process the bills yourself. With a 3% overhead, you hire like a bill claims processing company. So right now, Apple, I don't know who their ASO is, but Apple goes to Blue Shield and says, we're going to pay you X dollars to administratively manage, but we manage the risk. Yes. We hold the risk. We are paying for the cost. And what does that work out to? Maybe you don't know Apple's numbers, but if you pick a company for whom you know the

data, what is the cost per life that is typically paid for by a large employer in the United States today? Average, it might be $7,000. And with there being a financial benefit to self-funding or what we call self-insuring, it's usually just below that once you self-fund. So at the point of 500 employees or more, the vast majority of businesses in the United States have recently moved to self-funding. Wait a second. This seems crazy. Obviously, my company is very small, so we're not self-insured.

We pay an insurance company to take the risk. We pay way more than $7,000 per person per year. Yeah. Traditional insurance usually is more expensive. Now it's regional and it's based on the age of the employees and whether or not families are covered. But per person, that's generally the average expenditure in a self-funded plan. Now there's many variations. So a lot of businesses, let's say a business of your size, might say, we're going to take out stop loss coverage. So if anybody gets one of these giant bills over $100,000, that stop loss plan will kick in. There's 21 stop loss insurance companies in the US. They sell across state lines. It's very competitive. It works beautifully. And businesses

are saying, look, we'll assume the first $100,000 of risk. A lot of businesses can afford that risk, especially if they're saving money on the front end. And if they have a large enough patient population that they can spread that risk out. Yeah, exactly. This is the future of healthcare. And what's happening pretty soon, and the reason I'm so excited about healthcare is that doctors, primary care doctors are saying, let me help you. Let me move in. I want to be the doc for your company. I want to go over the occupational hazards on the factory assembly line. I want to talk about prevention and doing stuff immediately so that patients don't need to go to the emergency room. They can come to me for urgent care, then I'll sort of figure out. And the utilization is down, the costs are down, because if there's one story of a modern American medicine, it's that

price gouging has become an accepted way of doing business in certain pockets of healthcare. And as a business, you're very vulnerable. Okay. So now I want to dive into this quickly, but to do it, we have to set the stage for the listener. So I want to tell a story and then I want to talk some numbers. Here's the story. When I left medicine, the first thing I went and did is worked at a consulting firm. And what I got involved in just based on my background was on credit risk. When I left medicine, the first thing I went and did is worked at a consulting firm. And what I got involved in just based on my background was on credit risk. When I left medicine, I really left medicine. So I'm now a model spreadsheet jockey and we're working on something called the Basel II Accord, which then turned into two years leading up to the mortgage meltdown. I was part of a team that was basically now in the business of predicting how bad that was going to

be. And then once it became clear, it was going to be a catastrophe, figuring out how would you stem that tide. By the end of two years of that stuff, I actually understood pretty much everything one could understand about mortgage-backed securities and all of the ridiculous financial tools that were very eloquently described in the movie, The Big Short. Now look, you can watch The Big Short and in two hours, I think understand frankly 70% of it, but I spent two years knee deep in it and I understand 95% of it by the end of it. If you gave me another three years and said, Peter, I want you to devote yourself to this study of the US healthcare system. And at the end of that three years, I want you to devote yourself to this study of the US healthcare

system. And at the end of that three years, I want you to explain it to me as clearly as you could today explain to me how mortgages work, how they're securitized, packaged, credit default swaps, all of these things, and how it led to a calamity. I wouldn't be able to do it. And I can tell you this because over the past 10 years, I have tried to understand it, over the past 13 years actually. And I can't even fully give you the profit and loss statement of the U.S. healthcare system. Now, I don't think I'm the smartest guy in the world, but3 trillion goes in and $3 trillion gets pulled out. I don't understand how we can fix something when most people can't even wrap their heads around what's happening. especially when you master a certain domain of medicine, to be able to have no understanding about this gigantic industry that you're in the midst of. People came up to doctors all the time

during the health reform debates and said, what do you think? And the reality is, have we ever really talked about how we finance health insurance or whether or not doctor pay gets pulled out of nursing home payment allocations. We've basically been focused on two issues in terms of our doctors groups, doctor pay and malpractice reform, which is a whole nother subject. The big short beautifully explained that no, it's not a credit default swap. It's so complicated that nobody can understand. Leave it to us experts. It's actually pretty simple. It's just a way around insurance to do that. It's spending money you don't have. So what I wanted to do is in the book, The Price We Pay, create the big short for healthcare to explain things in a way that are understandable, relatable, and that touch on every area of

healthcare. And basically, because there is no silver bullet in healthcare, as you're alluding to, it requires a brief moment understanding pricing failures, a moment understanding the overtreatment crisis that we've created, and a moment understanding middlemen and administrative waste. And if we can tackle each of those subjects in one book in a way that people can walk away and say, oh, now I understand how a PBM or a pharmacy benefit manager works. I try to give an example explaining it like somebody selling Girl Scout cookies and how the money flows. All right. So use that example because PBMs, I think, I mean, it took me two years to understand what a PBM did. Again, I might not be the sharpest tool in the shed.

No. It annoys me that it took me two years to actually understand how PBMs worked. So explain it using this Girl Scout example. So let's say that a mom comes to your business and says, I'd like to be the exclusive seller and provider of Girl Scout cookies to your employees. You say, OK, that sounds good. I don't really know what Girl Scout cookies cost. But yeah, I'd like the idea of all my employees having Girl Scout cookies.

So this mom then brings in a bunch of kids who sell Girl Scout cookies to the employees. And the employees walk up and say, oh, how much is a box? Well, which company do you work for? I work for this company. Okay, then you just have to pay $3. Oh, because this mom sells Girl Scout cookies to many companies. She's the exclusive provider of Girl Scout cookies to more than one company. Yeah, but that's not why it costs $3. It costs $3 because that's just the co-pay of what the employee's paying for the box. The mom then charges the employer 50 bucks per box as the benefit. The employer's saying, oh, great. Thank you for providing Girl Scout cookies to my employees. You have 50 bucks

a box. I don't really know what they go for. Well, they go for $5. Sometimes in the real pharmacy benefit world, the employer is paying $6 a box of Girl Scout cookies, which covers the entire cost and some profit. And then they're still billing the employer 40 bucks. Now you would think the employers would say, this is complete bullshit. I know what you're up to. I know those boxes are $5 a box. You're gouging me. Screw this. I'm going to get another pharmacy benefit manager. I believe in competition. I want to put it out for bid. The problem is employers cannot understand the names of the drugs and the generic substitutes and the biosimilars and the bioequivalents and the different dosing schedules and the different

frequencies. So they literally get a report at the end of a year with, say, let's say you have 1,000 employees of 4,000 medications that you paid for as a self-funded or self-insured business. Which is different from saying there's chocolate chip, there's Oreo cream, there's vanilla mint. With cookies, it's easier because there's only chip, there's Oreo cream, there's vanilla mint. With cookies, it's easier because there's only like 10 flavors. Right. You can understand the market value. When you're doing it with medications, there are so many games. It's so hard to understand. I've talked to employers when doing the research for the price we pay that they get these reports and they're like, I don't know what the hell I'm spending money on. I can't understand this. And the brokers or the PBMs say, look, you're getting bulk discounts. Okay,

you're getting a 15% discount. And the employers, they look at these shiny objects and think, okay, well, I guess. And then there are all sorts of money games that they added on. Now, providing pharmacy benefits is a valuable service. I believe businesses should make a profit. So they should make a profit for the service. But what they've done is played a massive shell game with things that nobody can understand. Sometimes the pharmacists themselves can't understand why when you pay out of pocket, when you go to GoodRx, which is one of the apps I recommend people use when they need a prescription, go to GoodRx, and they'll tell you what the price of that drug is in all the places near you. Why is it that that price is often below what your employer is being charged? And it's sometimes even below what

your copay would be. Yeah, I did this actually recently. I had to pick something up. And so I'm a big fan of GoodRx as well. We should make sure everybody knows to use that. I'm actually friends with the guy who built the app. So I looked up what 30-day supply of this drug would cost if I went to buy it in cash because I'm so annoyed with how high my insurance premiums are. I keep saying to myself, why do I have health insurance? I'm not even sure I know anymore because the co-pays we get stuck with. I was telling you last night, I mean, I got an ambulance bill for $15,000 or something. It was just ridiculous. So I noticed that the cash price of 30 days of this drug was $227. It was fine. So I went to the pharmacy and I'd already paid for it with my insurance. So my

copay was 30 bucks. But when I looked at the slip, I saw that my insurance company was charged almost $1,000. So there's a bit of a disconnect here. My insurance company, who's charging me a premium to take care of my family that is, I think, beyond absurd, is getting gouged. They just paid $970 for something that if I didn't have insurance, I would have paid $200 for. How does that happen? So one thing that has come up in the recent case of the insurance executive who got charged $70,000 for a hip replacement, even though Medicare would pay $20,000 and the benchmark

blue book price is $28,000 or $29,000. How did he get charged $70,000? Now, he didn't get charged directly. He was responsible for something like 20%, a 20% of that amount. He's an insurance executive or leader in the field of insurance actuarial science. And he basically said, who the heck negotiated this rate? It wasn't a sticker price. It was the negotiated price between his insurance company and one of the big hospitals in New York. Why wouldn't they negotiate a better rate? And the article basically suggested that it's not necessarily in the financial interests of all insurance companies in all areas to really negotiate

the best rate. Why? Well, for a couple of reasons. One, there's something called the medical loss ratio or the MLR that was instated with the Affordable Care Act that said that insurance companies can basically only have a profit, if you will, of 20%. That is, 80% of all the money they take in for insurance premiums has to be paid out as claims payouts. I mean, I understand that and I applaud the idea behind that. But to say that,

well, let's just be completely wasteful with the resources to make sure we hit our MLR is crazy. Why not instead say, if you blow through your MLR, let's say your profit margin is 40% instead of 20%, just apply the extra 20% to next year's premium reduction. Well, if you can only make 20% of the premiums as profit, how do you make more profit the next year? Organizations like to make profit. You build in, you almost want more payouts and then build it into your premiums for next year. So the more they pay out, the more they can say, well, premiums are going up 12% next year. That gives them more money. I see. So you're saying they want to drive revenue as high as possible because they're only allowed to keep 20% of gross. Exactly. The higher the gross, the higher the profit. Yeah. Now,

I don't think I know a lot of insurance executives. I don't think they're diabolical people. I have really asked how intentional is this or passive is it? And I've heard it's mixed. Some insurance markets are very competitive, but this was in New York City, one of the big hospitals charging 70 grand. So the insurance companies may not be your fiduciary, your independent. And if I can just take an aside for one second, one of my biggest frustrations is the lexicon or the language that we all use. Oh, not to criticize

you, but I do this also. You referred to my insurance company paid that amount. Well, actually, you paid that amount in your insurance premiums. Oh, my employer paid the rest. Well, guess what? That's from the same pool of money of wages and benefits that you would otherwise get raised from. So this lexicon of, oh, my, the government paid, well, we're paying what a 7.5% Medicare excise tax on your end. And then if you're self employed, double that you're paying 15% Medicare excise tax, because otherwise the employer is paying, well, you're paying it's the same pool. Oh, the government paid, oh, Medicare paid, oh, the insurance company paid, oh, my employer paid. No, no.

The joke is on us, right? You've paid in so many different ways. People say that health care is now 18% of the GDP, and it may be as high as 16% of our federal expenditure, all of our tax dollars. In Massachusetts, guess what percent of all the state dollars go towards health care? 43%. I was going to guess 25. 43%. I just met with one of the recent legislators in Florida who's now in D.C.

working with us on price transparency advocacy. 43%. So people think, OK, 16% of the federal expenditure. Well, guess what? Guess where people are spending their social security checks? They're increasingly spending on those co-pays and deductibles. Is our health-related costs still the leading cause of personal bankruptcy? Yeah, it's the number one cause of personal bankruptcy. And FICA score is getting ruined.

And now, tragically, one in five Americans has medical debt in collections. What? One in five Americans has medical debt in collections. What? One in five Americans has medical debt in collections. And that seems, I mean, not saying I don't believe you, that just seems hard to imagine. FICA scores are getting ruined. People are paying more for their mortgages because they had a surprise bill that was unpaid. People are getting hammered out there.

And when we hear that health care was the number one issue in the midterm elections, it's really medical bills. People are angry. They feel they have no recourse. In some cases, I discovered in the book, the hospitals take the patients to court and garnish their minimum wage or paycheck. There's a court in Virginia, an hour south of my house, where if you don't pay your bill to that community hospital, they will take you to court within months, garnish your wages. And if you don't have a job where you prefer not to have your wages garnished, the court will ask for your ABA number and your routing number and your bank account number, and the money will just get pulled right

out of your savings from the hospital. Now, these are- Is this hospital a for-profit or not-for-profit? It's a not-for-profit. It's a not-for-profit. And the for-profit, HCA has a hospital in town and they behave. They stay true to the mission of medicine. They don't shake people down that are poor. I mean, you can shake down, look, a rich person who had plastic surgery and didn't pay their bill. I got no problem with you suing the socks off of that person. But that doesn't even happen because you pay up front for all of that stuff anyway, don't you? Yeah, exactly. Yeah. That's sort of a non-issue. That's a non-issue. But these are low income. These are poor people who work and have health insurance. They've done nothing wrong. They've showed up to work. They work hard. I've met several of them who are single moms. I was in New Mexico visiting a hospital for the book I profile in for the hospital I profile in the book We Price We Pay where

the hospital has sued half the town in New Mexico. The town only has like 28,000 people in it. They've sued half the town. The courthouse, when I walk in there, the clerk says, that's all we're dealing with here is hospital lawsuits. I said, what percent of your civil cases in the courthouse, when I walk in there, the clerk says, that's all we're dealing with here is hospital lawsuits. I said, what percent of your civil cases in this courthouse, in this town, is the hospital suing patients to garnish their wages? So very low income, blue collar towns, an oil town, mostly oil workers. And they said, oh, it's 95% of what we deal with. I said, how many in a day will you get? Oh, we could get 10 or 20 lawsuits in a day from the hospital. It's almost become like the court is now their collections department. And one woman, her car was in the shop for repairs. It cost 800 bucks. She didn't have the 800 bucks to get it out of the shop. And then she gets hammered with a $4,000 bill for taking her kid in for an asthma treatment that took 45 minutes. People are getting hammered

out there. And what we're saying, and what I'm trying to use this incredible platform that God's given me as a surgeon at Johns Hopkins is to say, this is not our heritage. This is not our profession. We have this incredible public trust. We need to stand up for our patients. I mean, just to take a step back from this, I don't think anybody listening to this right now thinks what you're describing is cool. I mean, this is totally unacceptable. The doctors think it's unacceptable. The patients think it's unacceptable. But the doctors and the patients aren't the ones that are making it happen. So you've got now two groups who are finding this unacceptable. One, because they're the ones

actually getting gouged That's the patient and of course and the physician who's saying Wait a minute. This just doesn't even seem right on first principles But how do we do anything about it? I mean, it's very frustrating because I grew up in canada I think it's totally overblown when people in the united states romanticize canada Let me tell you something canada does not have a perfect health care system So any of you listening to this who think oh we should just be like canada be careful what you wish for. Let me tell you something. Canada does not have a perfect healthcare system. So any of you listening to this who think, oh, we should just be like Canada, be careful what you wish for. Because I could tell you 57 horror stories of what it's like

to be a patient in Canada who tears their ACL and has to wait seven freaking months to get an MRI to confirm a diagnosis. And if you want to do anything else about it, good. Drive to Buffalo and pay out of pocket for your MRI and join the price gouging south of the border. So Canada is not a panacea either, but there is something in Canada and the UK and in other single payer systems that just makes sense. And it is the following. It is a budget, not a demand-driven system, and a single payer always owns the risk for life. Those are, in my humble opinion, two things that are sorely lacking here. I'll explain what those mean. I know you understand what that means. In the UK, the NHS has a budget. The budget determines how much they're going to spend on healthcare that year. In the United States, we have a demand-driven

system. You can predict what we're going to spend next year on healthcare, but the reality of it is demand determines how much we'll get spent. The demand is set by the patient and the provider. A lot of the stuff you talk about, the overtreatment, the unnecessary treatment. I want to dive into that, by the way, because there's so many interesting ideas there. The second thing is, I think I'm Blue Shield right now as my insurance company, but tomorrow, next time there's an open enrollment, I could switch and join Aetna. And then I could decide a year later, no, I want to go back and do United. I think there are probably stats on this that would suggest that the average tenure of an individual with a given payer is probably less than four years. So you have this portability

of risk. So if I'm in charge of Marty's risk, but I know that I've only got Marty's life for three years, what incentive do I have? Let's say you were just diagnosed with type two diabetes today. I know that in 40 years, I know that in 20 years, you are going to be a nightmare for me to manage from a cost perspective. Your amputations, your cost of insulin, because even though you're not on insulin today, you're going to be on insulin then, and the cost of insulin is another one of the greatest scams in the history of civilization. But in the next three years, are you really going to cost me that much? Nah. So I don't have any incentive to do what you described in the capitated system. I don't own your risk for long enough. Whereas in a single payer system, guess what? I own your

risk forever. So I actually have an incentive to do something about it. So I think it's that coupled with this demand driven system that has created something broken. And then notwithstanding what you just said, which is we don't have universal coverage. And I know that's such a politically charged topic. And I realized that in saying that you just take 50% of the population and you piss them off for saying we should have some universal coverage. But what do the polls actually say? I mean, I know this is such a political topic, which I don't understand why this is a political topic. Like to me, save the political topics for things that are political. But what is the public's

opposition to some form of universal care, at least to cover sort of primary care or some sort of basic expense? Like why is someone who makes $28,000 a year and has health insurance ever getting a bill for $4,000? What's the morality behind that? And when people understand that fact, how many of them still oppose a net that would prevent it? You're absolutely right that there's, has not been a traditional financial incentive to reduce long-term health complications and utilization because I even had, don't laugh, but I had one insurance executive actually tell me, actually, if we do some things that reduce long-term complications, we're actually saving money for our competitors. Now he didn't- Because he's basically acknowledging that whatever we do today, our competitors will

reap the benefit of because four years from now, this life will be my competitor's life. Yeah, this patient is going to be with a different carrier for sure in five years, with rare exceptions. People just switch jobs, they switch plans. He was being very honest with me. And I have this great relationship with insurance executives and hospital executives, where they're saying, Marty, you're right about these issues, but I want to do something about it. So he's being honest. And he's not saying, I deliberately do not want to invest in long-term health because I could save my competitors money. It's just there's no real reward financially to accompany the goodwill that we all have that we want what's best for patients. So that's what I love about

these, what I call globally capitated primary care that have lives for the long haul. And they're doing incredible things. And if you're a business, sign up with Iora Chen Med Oak Street, one of these globally capitated primary care, or get some of these local primary care practices are pulling together and saying, we want to go to the local business and we want to work with them. GM just signed a big contract with Henry Ford Health System, direct employer contract. I've helped some businesses do these deals, just sort of free service. I love it. It's the most exciting thing going on right now. But I think the reason why the outrage has been suppressed is just like we saw with the mortgage crisis and the financial collapse of 2008. People just don't understand what's happening, and the money games have sort of

been flipped around. So for example, if a business gets a higher insurance premium rate for next year, they'll tell their broker, this is crazy, 11% increase in one year, they'll say, well, the cost of drugs and the cost of the reality is, it's more the intermediaries, it's the money games. I have met a couple independent brokers. These brokers in the business routinely and almost always get paid a giant kickback from the insurance company or the pharmacy benefit manager for sticking an employer with one of their plants. And it's hard to watch.

You realize why people are paying too much. Sometimes they're not given the best options. I profile it in the price we pay businesses that said, no, no, I want another broker. I want an independent broker. And they just immediately save half a million dollars or a million dollars. And businesses all over America are getting ripped off right now on their health insurance and on their pharmacy benefit manager. So these brokers are not legally required to be fiduciaries? No, they are routinely accepting. So it's worse than real estate.

In real estate, you know your agent's not a fiduciary, but at least you know, at least you have transparency into what their commission is. It is worse. And it's, at least in real estate, you know there's a 6% commission. In this world of selling health insurance, which by the way, I've not met a doctor in America who knows how healthcare is sold in America to businesses. This is sort of when we were memorizing the Krebs cycle 12 times. How about substitute one of those 12 times for a quick lesson on how healthcare services

are bought and sold on a grid like energy. These brokers get a, say in New York, it's a standard 4% commission of every premium dollar the business will spend on healthcare. It goes to that broker who cut the initial one-time deal. They placed you. So imagine you're a real estate agent getting 5% for life. You're paying every year. It's a one-time cost, so it's not really a good example. But every year a business pays a million dollars, 4% goes to the broker who cut the deal. It'd be like a rental agent. Wait, wait, wait. You mean if you cut the deal in 2019 and the employer keeps going with that same deal, you continue to get your commission on the tail?

Yeah, 4%. In New York, it's regulated. Some places it's a little competitive, but generally, like in New York, it's 4% for life. So let me ask a question. What is the, if you use the word single payer, half the country loses their mind. You might as well say we want to resurrect Stalin and put him in the white house. Like it is such anathema to our existence. I don't know that a single payer fixes a lot of problems, but it fixes this problem. Yeah, it fixes this problem. So question one, why are we so morally opposed to a single payer system? And I'm not sure I would like it by the way, because when I see the single payer system in Canada, I can point out all of the flaws.

And two, is there a hybrid where you can get some benefits of single payer? Because almost everything I've heard you say so far is a cost center because of the complexity of negotiation. And so if you took out that complexity, you would eliminate the need for a broker. Why do you need a broker? I don't need a broker when I buy underwear. Why? Because underwear are freaking easy to buy and I can price shop myself. I mean, most things in my life I don't need a broker for because they're easy to buy. I mean, the issue here is you need brokers for things that are really complicated to buy. And I don't think there's anything, I don't think this is an exaggeration. I don't think there's anything more complicated to buy than health insurance.

I want to answer your question about the Medicare for all issue that's coming up, but real quickly, by the way, the brokers don't like this either. Okay, they went into this thinking, oh, I'm going to do something good in society. I'm going to work in healthcare, I'm going to help businesses and guide them. Then they find themselves in these traps where they're getting these cash flow streams, these retention bonuses, these threats from insurance companies. I profile in the book, a guy who basically got fired as a broker, if you will. They closed all books of business with him because he suggested to an employer they could get a better deal somewhere else. And it was one of the big Blue Cross Blue

Shield plans. They said, screw you. They wrote him this nasty letter. They trash talked him. They closed all his books of business. So all of his lines of revenue, all his steady commissions, and the bonuses on top of that all got shut down. That's catastrophic if you're a broker. They don't like living like that. I went to a broker conference, and I started talking to them, and they just started saying, look, this shouldn't be. This is a dirty secret in the business. We don't even like it. Write about this. And they gave me these stories and these spreads. But the Medicare for All thing, real quick, right now it's polling very high. The American public is very, very much liking the idea of Medicare for All. The Democrats are running with it. As you know, I work with both

Democrats and Republicans in the government. I brief, I advise, I try to be as independent as possible. Medicare for All is very appealing because all of these money games and this Mirage and Shell game all disappear with a direct Medicare for All system. Has anyone done, is there an independent think tank that's done the actual analysis and said, look, right off the top,

you're gonna save 8% of $3 trillion if you do that. Is there a sense of what the benefit is of making that type of a change? My research team's estimated that you save 15% right off the top. 15? Immediately, immediately, not even over time. And no journal's interested in publishing that. It's not a randomized controlled trial, but it's the biggest issue facing America, right? Now, here's the issue I have with switching over to this single payer Medicare for all system is that over time, historically, governments have shown 100% of the time, they cannot resist the temptation to make across the board cutbacks on healthcare. We've done it

in Medicare as a country. And so you go 10 or 20 years. Sure, you've cut all this waste initially. But politicians, governments, political will, they cannot resist the urge to just dial down, dial down their spending on health care. And then you're left with these dilapidated systems in parts of the UK or other countries where their spending on health care is just so weak that when the doctors, like in England, went on strike, the government's kind of like, well, you guys are civil servants, suck it up. And that's what I worry. And if we can accomplish these incredible efficiencies in the market to cut the waste, I mean, I've seen estimates that as much as 50% of our health care spending is wasted. And if you

look at the amount we spend per beneficiary, we're more than double what some countries are. The average person in the United States might have a total health spend of $12,000 per year on average. That's not self-funded. It's not your part. It's the overall expenditure. We are way, way over the curve. And we didn't spend this money growing up. When we showed up to the emergency room with a cut, you might have seen a bill for 100 bucks, but insurance always took care of it. Now there's a woman who was charged for just checking into the ER. She left before she went back into the emergency room. And she got this big bill for like 1200 bucks. I mean, the pricing failures have really hurt. So I'd like the idea of cutting out the waste, but I think if we can do it through free

market competition, then it's much better for the long term. So Marty, the flip side of there's advantage to a single payer system because you could cut out all of the machinery that's necessary to make a market understandable. The flip side is, but a free market works better. And I think that's generally true. I mean, it's hard to argue that capitalism works. It's hard to argue that it's the least bad option, maybe to put it mildly. It's hard to argue that competition is not a good thing. So what's the argument that says, no, no, no, no, no, no. A single pair of systems, a disaster. We want to stay with this sort of system that has multiple different competitors across every spectrum from hospital systems to that are each competing to do the best to payers, to PBMs, to brokers and all

of these things. So what's the argument that says, don't leave that, but let's just re-channel it. Yeah. Well, I mean, one of the big tasks I've been trying to do is educate the American people. I describe the book, The Price We Pay, as the big short for healthcare. If we can educate employers, everyday Americans, how to buy drugs, how to buy health insurance, how to ask the questions, get second opinions, challenge their bills, recognize that when you get one of these massive bills, you're not legally obligated to pay it. And we're making these legal cases to judges across America.

I've got a group of pro bono lawyers as a part of this restoring medicine movement that we're assigning to individuals and we're swimming in cases. I mean, there's just unlimited cases out there. One in five Americans have medical debt collections. Well, some of those go to court. We're basically telling the judges, there's no legal contract. How can I mow your lawn and then send you a bill for $5,000 and say, well, that's what I charge? I mean, you'd say we have no legal contract. How could I cut your hair for 30 bucks and then one year you come in and I say it's $900? There's no legal contract. So this is a very important point,

Marty, because I didn't know this. Yesterday we had dinner and one of the people we had dinner with who's just amazing. We could go off on stories on how amazing that guy is and his work. Yeah. African doctor. Yeah. But he told a story of his son needed an endoscopy and they're back in the US for this. And so to get an endoscopy, which is a tube that goes into your esophagus and your stomach and takes a look around and comes back out and makes sure everything is okay.

They have a lot of fees in there. You've got the fee for the gastroenterologist who's doing it. There's a hospital fee for that. There's an anesthesia fee because you need an anesthesiologist to give you some sedating medication. So you're not under complete anesthesia, but you're comfortable so that you're not gagging at this thing happening. And it turned out that the hospital was inside the network.

The professional fee for the gastroenterologist was quote unquote inside the network, but the fee for the anesthesiologist was not inside the network because for no reasons that this patient could ever understand, the anesthesia bill came from a group that was outside of the network. So he got a bill for $10,000 for the anesthesia portion of this, which let's just call a spade a spade, Marty. That's putting an IV in somebody and for 30 minutes taking care of them after you've administered some propofol. I mean, let's just be completely honest about what actually happened there. So a few dollars worth of propofol and some IV equipment and an EKG and a pulse oximeter, and you're watching someone for 30 minutes. So I might be in the wrong

business, by the way, if that's 10,000 bucks, that is insulting to what money means. So there's two issues I'd like to understand there. One, what in God's name does it have to do with the fact that that was in or out of network, that such an egregious charge could be levied on that patient? And two, what is the legal obligation of that patient and how can that patient fight and say, this is totally bullshit, we're not doing this? Well, right now the judges have been sympathetic to the hospitals and we're trying to show the legal argument that there's no contract. When you walk into the emergency room today with a cut, chances are they're going to give you some form and say, you have to sign this. And the person giving it to you doesn't know squat about what's in it.

You could be in excruciating abdominal pain and need to go have your appendix removed. You're signing it at a vulnerable time. Well, and in fact, let's take a step further. If you have a prenuptial agreement and you want to get that held up and there's any evidence that that was signed under duress, guess what? It doesn't matter.

And I don't know about you, but an acute abdomen sounds like duress. Yeah, I mean, if you're in a criminal trial and somebody says, gives the key evidence that somebody murdered somebody, the other lawyers could argue entrapment. He felt a little pressured to offer that confession and then it's negated. And yet in the hospital, not only is there no contract sometimes, but there's this document

that is fooling you into thinking it's a consent to be treated. But there's a law in the United States called EMTALA that requires any hospital to take care of any urgent or emergent patient that walks into their door. It's not dependent on giving your credit card when you check in. It's not dependent on giving your social security number and your mom's address and all these other things that they try to collect. You don't have to do that. Hospitals are required by law. It's called EMTAL, to take care of anyone with an urgent or emergent condition. If you feel that there's a legal document that you have to sign your home and your financial life away in order to get stitches, and you're concerned about predatory billing, you sign in that little signature box in the iPad, you sign, did not read. Because no one's going to read what you sign in there, okay?

No one's going to read what you sign in there, okay? And then when the collectors call and the judge says, you have to provide your routing number and your account number, or we're going to garnish your wages, you say there's no legal contract. We're trying to empower people in the United States to say, we need a competent and fair pricing system. The surprise bill issues, by the way, people are getting hammered. The surprise bills right now, hammered. And why are they so hard to understand? I'm taking you off that question, but I get about

three EOBs, explanation of benefits, per month. Maybe four of them. I feel like there's a never ending stream of them. You take your kid to the pediatrician because he's got a fever and you think he might have an ear infection. The pediatrician looks in the ear, confirms that he does. You get some amoxicillin. You go home. Everybody's happy. I get six EOBs for that encounter, each one saying something I can't understand. This is what we build. This is what your insurance company paid. This is what you're responsible for.

And then they attach a check to it. And I'm like, what? I don't get it. And again, if I don't get it, at least one other person listening to this doesn't get it. Right, right. Well, look, I took one of those bills to a hospital CEO. Like I said, I've got great relationships with a lot of these hospital CEOs. Quite honestly, sometimes they're just disconnected from what's happening with their revenue cycle department.

Don't you love that word, revenue cycle? Collections. Revenue cycle. One woman handed me her card and it literally said on it, Director of Revenue Enhancement. Like, what the hell is this? Oh, gosh. Hippocrates, man, would just be rolling over in his grave. It's funny.

I hope that the guys in the mafia are listening to this and upping their game a little bit. Because if you're running collections in the mafia, you should at least have a revenue enhancement card. Well, in Florida, drug dealers have given up drugs and turned to doing medical fraud because it's more profitable and they can make more money. I don't know if you know, but the Medicare anti-fraud offices, I know the head of the division, they've essentially closed down most of the regional offices and moved them all to Florida because Florida is just the rampant center of a lot of abuse. So you show an EOB to a hospital CEO. Yeah, they can't even interpret the bill. I mean, there is a buddy of mine who had a friend get a $5,000 bill for an hour in

the emergency room or something like that. Did a couple simple things and the bill was over $5,000 bill for an hour in the emergency room or something like that. Did a couple simple things. And the bill was over $5,000. Took it to my friend who's a consultant, knows the healthcare executives. Went to the CEO and knew the CEO. He said, by the way, my friend went to your emergency room. She was in the ER. She got a little oxygen nasal cannula and an IV and was sent home about 45 minutes later. Guess how much the bill was? And of course, he's cringing, embarrassed. And he says, I don't know, $1,500. No, it was 5,000. Oh, my God. You know, he's like, let me take care of that for you. And there's this embarrassment when it comes up that, yes, we've allowed this game of dialing up bills and then offering these bigger discounts as shiny objects to employers and insurance companies has gotten so out of control that the victims, because hospital CEOs will often tell me, Marty, you're so right, but nobody pays

those bills. Those are sticker prices. We give discounts liberally. Well, not to the people I'm meeting in Fredericksburg, Virginia and Carlsbad, New Mexico, who are fighting their bills and they can't even get a call center representative and they're being harassed and the collectors are calling saying now it's in the hand of collectors so you can't talk to the hospital. And let's explain what that CEO is trying to explain to you, which is, look, we want to make this look really good. So something like coming into the ER, having a nasal cannula, an IV and an EKG and sending you out, we're going to put a sticker price on that of $5,000. And we don't really think anybody's going to pay it. But what we're going to do is we're going to tell the insurance company or the employer, we normally charge $5,000 for this.

But for you, my friend, today, one time only, if you sign up now, this will only cost $500. And you're thinking, it's a great discount. We're all over it. And if a different company shows up, they might get a different rate. They might get a different discount. So different people can get different discounts on the same egregious price that serves no purpose other than to make you feel like you're offering a great discount. I mean, can you imagine if the rest of the world ran on this principle? Walk into a grocery store. Yeah, exactly. The restaurant. I'll have the tikka masala, please. Well, here's the deal. Who's your employer? It's $1,000. Who do you work for? I work for Walgreens. Oh, take this menu. Well, here's the deal. Who's your employer? It's a thousand dollars. Who do you work for? I work for Walgreens. Oh, take this menu. Well, the tikka masala is not a thousand for you.

It's only a hundred dollars for you. And the guy sitting across from you works somewhere else. And well, it's $50 for him. Right. But he gets a 2% discount. On the 50. On the 50. Yeah. So he's only paying 49. Employers tell me all the time, our insurance company, we get a 40% discount. On the 50. On the 50. Yeah, yeah. So he's only paying 49. Employers tell me all the time, our insurance company, we get a 40% discount. Well, I'll give you a 99% discount if I'm selling you a car as long as I get to set the price. You can have a 99% discount. Is there another example in our economy that works this way? Well, there is bulk purchasing and retail, but here's what I would add to your example that you very well described. In addition to these secret discounts, both parties are sworn to secrecy that this discount cannot be made public.

And that kills the competition. And that's what we're working on with legislation. And that's legal. It is legal to put a gag on the chicanery. Yeah. Okay. Legal to put a gag on the chicanery. Yeah.

Okay. So going back to our friend from yesterday, the reason he gets a $10,000 bill for someone putting in an IV and some propofol is because the anesthesia group set a price that was ridiculous, not necessarily expecting people were going to pay this out of pocket. Again, they didn't go into this trying to kill people. For whatever reason, the anesthesiologist who was probably supposed to do that case was maybe not. So someone else comes in, they're out of network. And now that ridiculous price actually sticks to this patient.

Now, what is his legal recourse in that situation? He got overcharged. Yeah. I mean, what we're telling them is you argue as strong as you can argue to the collectors, to the courts if they take it to court, to whoever, that they need to provide the legal contract. Sure. Oh, they're charged.

They want $10,000. Just send me the agreement. I understand it's part of my consumer rights that when a collections agency calls that I'm entitled to see the contract or agreement that obligates me to pay. What type of contracts are being produced at that request? Well, I've never seen a collections agency produce a contract because it's that little iPad form that you sign in the lobby or something that doesn't exist or it's combined with a consent to treat.

So it doesn't exist at the beginning. So let's say open enrollments every January. I mean, I'm sure we sign something in January when we enroll. Is that the contract? Is there something in there that the collections agency can come back and say, well, Marty, I'm not going to show you a contract from when you were in the ER in May. I'm going to show you a contract from January when you signed up through open enrollment. No, because that's a contract between you and the insurance company. It's not a contract between you and the medical center. And they're the party that's going after you. So this is a great point. So the only time you're being technically presented with a contract for price is at

the provider's level. And we're basically saying it's very easy to render that contract null and void. Yeah. And sometimes it doesn't exist. Or logistically, honestly, they just can't produce it. They send what they call bad debt to the collectors. And the collectors go after you, but they're not sending. I love the idea of signing did not read. Did not read. Exactly, right? Oh, no, I never entered a legal agreement obligating me to pay.

If I did, show me the thing. The other thing we're telling people to do, if it's really egregious, contact your state's attorney and contact your local news network. Now, unfortunately, some of the local news networks, their number one client is the local hospital that's running ads. This complex is gigantic. It's incredible. But contact them and tell them. My friend Sarah Cliff at Vox, Elizabeth Rosenthal at Kaiser Health News,

they each have sections where you can send in your bills. I'm swimming. I'm underwater. I've got, I don't know, 54,000 emails I haven't read. Probably half the number of emails you have and have not read. I'm going to try to clean it out this weekend. But so many people are getting hammered out there. It's like an unlimited drinking from a fire hydrant.

But those are things people should do. Ask for the contract. Sign if you feel like it's not a fair agreement. If you're not disclosed prices. I wish I knew this two years ago when we got stiffed with some $15,000 bill for an ambulance ride. Well, you know, one of our friends from residency that had a sort of a catastrophic medical illness in Australia. Yes. And he was flown back. We all paid money to chip in for this. There was a whole Facebook page where we were all kicking in thousands of dollars for his care. I mean, yeah. So what happened? I don't want to upset you, but some of that money.

Do I get a refund on that? Was that all given back to him? I mean, this guy's one of my best friends and it was awesome to see everyone come together. But the flight back, they charged him like a quarter million dollars for that flight. You could get a private G7 and fly to Beijing and back five times for that money. That was just pure price gouging. And actually, I got him some legal help to knock that bill down. Because this came outside of his insurance? Like his insurance decided they didn't cover that kind of stuff? Bingo, you just nailed the number one story of the modern American healthcare system. Entities, organizations, doctors, hospitals, ambulances, helicopters

have figured out if you bill outside of insurance, you can just gouge. And some people will pay it. And if you just send it to collections and harass and send them 50 bills, some people will just pay it. And the reality is God's been good to you and I. If we got a $5,000 bill, we'd find a way just to pay it. It might be annoying, but we'll find it. But half of America has less than $300 in savings. People are getting hammered. Oh, God, that's so upsetting. Now, can I talk about something positive on this subject? Yeah, please. Please, for the love of humanity.

Talk about one good thing here. Keith Smith in Oklahoma City has basically said, this is total BS. I don't understand how a doctor can take an oath, treat a patient, and ruin their life financially. It's against everything I've ever considered sacred about this heritage of medicine. He has offered one bundled price for every service at his medical center. If you come in and you need a shoulder surgery, you don't get a bill for the epidural separate and for the anesthesiologist pro-feed separate. They got their act together. And hospitals need to get their act together instead of sort of the finger pointing of, oh, well, that's the lab. The lab's billing you separately.

We laugh at this because it's so true. It's pureouging and we're all paying for it it's not oh my insurance paid or my medicare paid four thousand dollars to test for one gene allele you can genome your whole 23andme cost what 150 bucks and that's like all these gene tests so we've seen that genes that are in the 23andMe panel build separately for thousands of dollars. So people need to ask when we all started, and I have you to thank a little bit for this, started asking about healthy foods. You remember that conversation early on when you were learning about this subject and you're like, Marty, this is incredible what I'm learning. I started asking in restaurants, what kind of food is this? And does this have this? And how

is it prepared? And it's putting pressure on the restaurants. It's driving the market, the food label world. The food industry is now trying to say, hey, this has these healthy ingredients that are good. This has no added sugar. And so the inquiries are moving the market. And in addition to Keith Smith disrupting healthcare in Oklahoma, and it's awesome, the insurance companies hate him, the hospitals hate him, right? All these people want him to fail. It's like Elon Musk. Everybody's shorting.

Everyone wants him to fail. But he's actually growing like crazy. People are flying in from Japan to Oklahoma City. Why? Because they have a fair and honest bundled price. He had 200 Canadians, I think, last year. We did a study at Hopkins of all the price transparency medical centers in the United States. Before and after, they decided to go full, honest pricing. Not charge master pricing,

but the real price. Not, oh, here's a price, and we're going to give you a discount of 2%, right? The real price. And they all do incredibly well. Their business goes up. Their satisfaction goes up. We publish the study. This is the future. It's exciting. It's disruptive. It's why I'm so up on medicine right now. And you think that this is potentially a better solution, which is basically still private health care, but with market demanded transparency. I do. I do. Look, it's very appealing to wipe out all the money games overnight with a single payer system. It's very, very tempting. And you know what? People are advocates for it are absolutely correct. It will slash the money games overnight.

It'll just put it to a screeching halt. But over time, historically, if you look academically at every government that's done it, they cannot resist the temptation to just skim cut, skim cut year after year, 10 or 20 years. Yeah. And I don't want to live in Canada. I mean, I don't want to live in a Canadian health care system either because I see what my parents experience. I see what my whole family is still in Canada. Every single person in my family is still in Canada.

And I wouldn't trade places with a single one of them for their health care, even though average, it's infinitely better than American health care in terms of accessibility and cost. My dean of Harvard School of Public Health when I was a student said, Canadian is essentially an unarmed American with health insurance. No, I agree with you. We have an incredible health care system. The problem is it works for the wealthy and it works most of the time and the reliability is not there. But the only reason it works for the wealthy is something you said a moment ago. It's that the cost of the care for the wealthy falls below the hurdle rate of hassle. I mean,

is there any place in the country that someone of means would rather get their healthcare? No, I don't know the last time an American of means left the U.S. to get their health care. It's the exact opposite. Hopkins, I feel like half the people we took care of were outside of the United States. So there's no question that we have the best health care when it's applied correctly, which is to say the quality of care we have the potential to deliver is exceptional under the right circumstances. That's a lot of caveating. We have a cost crisis and we have an access crisis. And the two people, the two subsets of people who are therefore going to be crushed in the US healthcare system are people who cannot afford access at all and people who can't afford

egregious costs when levied upon them. If you're not in those two camps, you're going to be okay. It's annoying as hell, but you're going to be okay. And I think that's what's allowed this system to sort of limp its way along. And I guess what I'm hearing you say is we might, and I hate to use the term tipping point, but we might be at a tipping point where it's become so egregious that even the people now who, A, there might be enough people that are moving into the latter categories of, okay, this is now, if one in five people are getting collections through healthcare, I mean, we have a fundamental problem. Half of women with stage four breast cancer in the United States

today, recent study just came out at ASCO, half of women with stage four breast cancer in the United States are being harassed by medical debt collectors. Did you talk to the medical debt collectors? Well, that study was published by another group. Oh, no, but in general. Oh, yeah. And are they feeling, I mean, how are they feeling? Let's try to do something we talked about earlier. Let's try to have empathy for them. You need a job. Everybody needs a job. So I got a job. I'm a medical debt collector. Do I feel good about myself? I mean, I'm calling a woman with stage four breast cancer every day and threatening her. That's a good person that's on the phone. I don't believe that that medical debt collector is some like evil incarnate. No.

So how do they feel about what they have to do? Well, some of them hate their life. I would say for the most part, they are glad to be in a position where for the most part, position, where for the most part, if you object, fight your bill, they're going to just knock off 20, 50% right off the top. And this is another tip for people out there. Bills are negotiable. When you get your bill, they are negotiable. I wish I knew this when I got that goddamn ambulance bill a few years ago. Yeah. I mean, imagine they're kind of hoping that you, I don't want to say hoping, like you say, we have all good people working in a bad system. But the business model relies on some people just saying, oh, screw it, I'll pay.

And entire careers in industries. That could be a slogan, right? The business model is, quote, ah, screw it, I'll just pay. I'll just pay, right? And these folks in the so-called revenue cycle world. They're in revenue enhancement. It's revenue enhancement. Revenue enhancement.

I mean, how did I discover these people? I get invited to speak at a lot of conferences as you do. I never actually get invited to speak at conferences, by the way. Well, consider yourself invited to every one I've done. No, no, I'm happy to not. So they say, I got invited to this conference of revenue cycle managers. And I just, sure, I'm happy to not. So they say, I got invited to this conference of revenue cycle managers. And I just, sure, I'm happy to speak to them. It's nice. That's awesome. I mean, that's a great opportunity for you to learn. Yeah. And that's basically this book,

The Price We Pay, is a two-year tour around America talking to patients and revenue cycle people and businesses and brokers and everybody. I wanted to talk to everybody and get their point of view. And I don't believe there's any one bad villain. I think it's the system. But the revenue cycle people, I show up and I'm like, I'm sorry, I just got out of the operating room and flew into town. Who are you people? What is revenue cycle?

What do you do? And is this in health care? Are you outside of health? What is it? Are you tax accountants? And they explain to me how it works. And I look out, there's a conference of like 4,000 people. And I'm like, does every hospital have one of these? Oh, yeah, every hospital has a department. At Duke,

at one point, there were more people working on billing and revenue cycle than there were beds in the hospital. Come on, that can't be true. No, this is a true fact. I think they had 900 beds and they had it just over that in terms of billing, coding, and revenue cycle and managing these discounts. Okay, so let me give you another contrarian argument. If you fix the healthcare system, how many people are going to lose a job? A lot. Healthcare is an enormous industry. It employs tens of millions of people. Yeah. What are those people going to do now? Well, you can make the same argument about the financial mortgage crisis. You had all these people selling subprime mortgages and getting rich and employing other people in these giant companies. Healthcare is a gigantic bubble right now.

And the parallels to the financial crisis are striking. And at some point, if you think about it, we are spending money we don't have on products that we don't even need sometimes. The PBM world, medical services that are unnecessary, the enormous middle layers. And doctors, quite honestly, are very suspicious of what's happening. They don't understand. I mean, I didn't understand until I started touring and going to these conferences and saying, I'm sick of this. I'm a professor of health policy. I don't feel like I have a handle on the entire healthcare system. And I decided enough is enough. I want to learn, educate myself on every tiny detail of this

ginormous system. I want to know every law, Medicaid rule, insurance, contract negotiation, talk to the negotiators. What goes on at that meeting? Well, they say, our prices are going to go up by 10% next year, but we're going to give you a 12% discount. And then they turn around and dial up the prices 15%. And then the hospital says, oh, good job, Bob. I'm just making it up. You generated another $4 million for us. You're now promoted to whatever title. This gigantic industry. And they're coming up to me at the conferences and other places and telling me, I do this and this, but quite honestly, my job doesn't need to exist. If we had honest and fair pricing in America, we wouldn't need this

gigantic negotiating of discounts and markups, the markup discount game, I call it. And one important thing, and one thing I'd ask you and all your listeners to do is use the honest lexicon, just like we talked about medical care gone wrong versus a preventable adverse event. Let's use the patient-centered terms. Let's talk about prices and not costs. Let's remember that we're paying, not our insurance company or our employer or other folks. Let's talk about bills you shouldn't be getting. Refer to them as predatory billing practices or predatory medicine, screenings you don't need. So let's talk a little bit about that. You talked about how studies have looked at what percentage of tests that physicians order do they deem unnecessary? So in other words, you go and you poll a thousand doctors and you say secretly and confidentially, so no one's going to come and

spank you for this. How often are you ordering a test that is unnecessary? And the answer turned out to be 21%. 21% was the average. Now actually, yeah, yeah. The average, sir. The question said, 21% was the average. Now, actually, the question said, excluding your own practice in your observations. Got it. Okay. Okay. As we develop practice pattern measures of waste, which is a big project we're doing at Johns Hopkins with some other groups, we've asked doctors, tell us about an egregious area of overuse in your specialty, something that's done too much in a certain clinical situation. And sometimes they'll be like, I can't really think of anything. And then we'll say, well, think about your competitor groups. Are they doing other stuff? Oh my God, yeah, they're doing

endoscopies every six months after an initial screening. They're doing 50 biopsies and all this stuff. So it's easier to get an answer when you don't force the lens inward. Right. And I think it's back to our opening conversation. We work our tails off in residency. How dare we start saying that you've crossed over to an area of entitlement and burnout where you do too much unnecessary. Let's talk about the system. It's not a threatening. We talk about low value care in the medical literature, and that's how we're talking about this subject. Now you could take a couple of those into, I've always thought of this as an area that doesn't get enough attention because I sort of divide it into two categories. So let's take one of the most egregious examples, which I'm sure will upset a few people, which is interventional cardiology. There's a lot of people already upset

from the podcast. Yeah, we've upset a lot of people. Okay. So the medical literature on stenting is like all things in the medical literature. There's some room for interpretation, but there are some things that we kind of know. So if somebody is having an ST elevated wave MI and they're hemodynamically unstable in the emergency room, those are patients that do a lot better when you put a stent in them. This can be life-saving. Yep. You're going to save that person's life. So we're here to say stents are not bad. Okay. But then there's a whole body of literature that makes it also pretty clear that there are a whole bunch of people that don't seem

to get any better with stents, meaning there's no evidence you're going to save their life. And that's not the only reason to put a stent in, because if you save a person from having another heart attack, that might be a reason. Anyone who's had a heart attack would say, I don't care if it reduces my risk of dying, but just not having a heart attack would be a benefit or if it reduces chest pain. So you have this whole other group of people who actually have no benefit of a stent, doesn't reduce chest pain, doesn't reduce subsequent heart attack, and it doesn't save a life. And then you get into the business of, well, how many stents should you put in? You know where I'm going with this, right? There are interventional cardiologists out there that

are putting stents in people and violating every aspect of what is known. Meaning they're putting them into the wrong patients and they're putting in far too many and they're getting paid by the stent. Okay. You've actually talked publicly about this in the dermatology world about people doing Mohs surgery. That's one type of bad actor in the system. And you could argue some of that is conscious, some of that is subconscious. So it might be the case that that doctor who is putting five stents in the person with stable angina, who's never shown even evidence of MI or EKG change, deep down is a good person and thinks that they know something that none of the studies have

ever shown. And I get that. Okay. And then within that, there's going to be some nefarious actors who are simply used car salesmen gone wrong. I just realized I insulted a bunch of used car salesmen, but there are people who are literally just shaking down the system and they know that they're going to get a thousand bucks for every stint they put in. So I'm going to put five in this guy today, even though he probably needs zero. My impression, which could be entirely incorrect, is that the majority of unnecessary care is not in that category. It's in a different category, which has two ends to it. One is the, I don't have the time to deal with figuring out exactly what the right thing to do is. And the cost of me giving

in and giving someone an antibiotic when I'm pretty sure they have a viral infection that's going to go away in three days, the cost of me trying to educate the patient on that and explain antibiotic resistance, it's just too high. I've only got 15 minutes. I'll just give them the goddamn Z-Pak, right? That's one. And then the second subset of that, which by the way, I think is the worst one, is the, I'm not going to be the guy that gets sued because I didn't order the head CT on the person with a headache, even though I know that this person stopped drinking coffee two days ago and they went from three cups of coffee a day to nothing and they're coming in here with the worst headache of their life.

And I'm pretty 99.999% sure it's caffeine withdrawal. But I'm not going to let this person walk out of this ER without a head CT. Because if, God forbid, it's a tumor or an aneurysm, I'm going to get sued. So everyone gets a head CT. I mean, I told a funny story last night at dinner that I won't repeat. But of a patient coming in with complaining that their hair was vibrating and they get a head CT because the ER docs like as an individual, I know that's bad for the system, but as an individual, it's in my best interest to do that. Or one time I saw a patient with hair vibrating and I got a CT and it showed a cancer. Yeah. I'm like Osler reincarnated. I'm so good. I suspected that that vibrating hair

was actually a meningioma beneath the surface. This to me is a very dirty problem in America, which is we are a very litigious culture. And it is that. So when people talk about medical malpractice, which I want to come back to because you alluded to it, people tend to be dismissive of it and say it's not actually that big a part of medicine because they're looking at the actual cost of medical malpractice. What I think they're missing is the threat of medical malpractice has created a culture of completely unnecessary testing as part of the CYA fellowship that everyone gets taught in medicine. So somewhere down the line, each of us in residency was taught cover your ass, which means you are doing stuff that is not good, but it is going to look good in a deposition in the worst case outcome here.

Now, how do you fix that problem? Good medical care. So for every five docs in the ER that will say, if somebody has a headache, you just, for liability reasons, need to get a CAT scan or an MRI. I bet you there's a senior doc who says, no, you don't. Look, people are more likely to sue you because they're just angry at you or they're incredibly dissatisfied than because you failed to order a test. And do the right thing. And you can defend it if you need to defend it, that the patient had a moderate headache. And so really good sound judgment. I mean, I love these very senior wise doctors that

say do the right thing. Don't just react to some fear of a potential risk. The unnecessary testing and unnecessary doing things because of malpractice concerns is definitely a problem in certain pockets of medicine. The emergency room and OB, they're getting hammered in OB. But it's not the driver. You know, people, it's so vivid to us doctors, and it seems so wrong and so unnecessary, and you want to blame these lawyers that have these contingency games. The reality is, it is such an inconsequential small fraction of the medical spend,

even though most doctors think it's one of the primary drivers of our higher health care costs. When you say it's insignificant, you mean the actual cost of malpractice insurance litigation and things like that? Well, not just that, but studies have shown it's not just doing stuff that costs money, but you are avoiding things because of malpractice concerns. People may avoid surgery. I don't want to touch this guy because if something goes wrong, I don't want to have that liability. So you also have avoiding care because of malpractice concerns. I remember once in clinic a discussion coming up with a patient that was an attorney.

And the attending said, complex case and an attorney don't do it. I mean, are you asking to be sued if something goes wrong? Yeah. So how many unnecessary head scans the Medicare pays 300 bucks for, did that one of operation avoidance balance out? So if you talk to the real scholars of healthcare costs, they'll tell you it's not malpractice. I know it's an emotional issue. So yeah, and it's not the malpractice, but you're saying even the over treatment to minimize the risk of it. So what about another thing, which is, do we have a culture of just expecting that? Like, so how many times has you got that patient who comes in who said, I stopped drinking coffee three days ago. I've got a really bad headache, but I'm really worried.

And is there ever room for the discussion that says, look, in my judgment, and I've already talked to three of my colleagues here today, we all think that your headache is from caffeine withdrawal. And we think you should take Tylenol and maybe have a coffee and maybe taper off as opposed to just going from three coffees to zero coffees. But if you really, really want a CT scan, we'll do it. It's going to cost this much. Now your insurance company is going to cover this much, but you're going to cover this much. I mean, that seems like a reasonable discussion. I mean, again, it's artificial in that I can't imagine an ER doc having the luxury of time to sit down and have that, let alone the transparency

into pricing. But to me, that's the way the world works in everything else. I mean, Marty, if you want to buy a Ferrari, you can. You know how much it costs and you would presumably decide that car is worth more than a house. You would make that decision if you felt that way. So in theory, you should be able to say to people, look, I'm your advocate here as the doctor. I don't think you need a head CT. If I was in your situation, I would not want the radiation. I think people don't understand the radiation they're getting in CT scans. A hundred times more than an x-ray. I don't think you should be allowed into a CT scanner without someone telling you how many millisieverts you're getting and

showing you the NRC guidelines for how many millisieverts of radiation you should be exposed to. And look, I order CT scans on patients all the time, but I have this discussion. It's like, okay, you're allowed 50 millisieverts of radiation a year. We're going to do a CT angiogram in you, but in this facility, it's 2.2 millisieverts. And you're going to pay this amount for it. If you go and do it over there, it's 18 millisieverts and you're going to pay less. Your choice. Great. To me, that makes sense. So I guess I didn't realize that. I guess I thought it was a bigger problem, but you're saying the data say that's not an issue. It's a small issue. It's less than three-tenths of 1% of the overall healthcare cost crisis. And that's been

studied many times, but yet it's vivid and we're proximate to it cost crisis. And that's been studied many times. But yet it's vivid and we're proximate to it as doctors. And to be honest with you, like you say, healthcare has a lot of things that we don't understand. And here's one thing we see and we understand and it just seems wrong. And that's why it's disproportionately dominating the discussion of healthcare costs.

The reality is my malpractice insurance, it's about 40 some thousand dollars a year as a surgeon at Johns Hopkins. It's been about that for 25 years, but yet premiums go up seven to 11% a year. For health insurance. For health insurance, for what we're spending. Yeah, yeah. So I mean. So if you're going to rank order the things, I mean, you've pointed out an enormous one. If simply, if bogus discounts in middlemen is 15% of it, that has to be the single largest item then, isn't it? Well, that's just the pricing failure piece of it. And that's just an estimation. So then you

add to that 21% of healthcare services are unnecessary, according to this survey of 2000 doctors that we did at Hopkins around the country. If they're saying that 21% of everything we're doing is unnecessary, there is a huge cost reduction opportunity if we can focus on appropriateness. What about drug pricing, generic versus non-generic? I mean, that seems to be another place where the United States pays disproportionately more than anyone else in the world. Yeah, absolutely. Another piece of it.

I mean, that's where people are coming up with the stats that roughly half of our healthcare spend can be chopped off and we can still deliver high quality healthcare that has better patient. So what about the counter argument? Counter argument would say, look, pick your favorite drug. Americans are going to pay two times more than anybody else. In some cases, much more. I mean, we sometimes use a Canadian pharmacy for our patients for really expensive drugs, just on principle. It's not that the patient necessarily can't afford it, but I just say to them, look, I'm morally opposed to the fact that you're going to pay $30 a pill for something that I know in Canada is $1.97 a pill. And that example is actually true. And if I'm going to give you 300 of these for a year, I'd much rather you pay $2 a pill

than $30 a pill because your insurance won't cover this, by the way. The counter argument is, yeah, yeah, yeah, yeah, yeah. We have to pay more for drugs as Americans because we're reaping the benefit of drug discovery. All the best drug discovery is taking place here. These are our companies, which by the way is not entirely true. And therefore we subsidize the rest of the world's drug costs because that's the price we pay for being the innovator. Is that kind of a bogus argument? You're absolutely right. Pharma companies, when they develop drugs, are factoring in, they're sort of budgeting the profit down the road into the drug development price. So if there's bigger profits in the US, that's all part of the investment that they make in the research.

Problem is with drug pricing is there are so many moving parts. And what I've seen is, first of all, as a cancer surgeon, some of these drugs do miracles and save lives. It's just incredible what we're seeing. Biologic agents now are working wonders in part because it's a whole different generation. These are not small molecules. These are expensive drugs to develop. They're immune-based medications.

Yeah, Keytruda is just unbelievable. molecules. These are expensive drugs to develop. They're immune-based medications. Yeah, Keytruda is just unbelievable. Unbelievable. And it's getting more awesome, and we're seeing lives saved. What we're seeing is a couple bad actors engage in the business of price gouging. We're seeing a couple bad actors transition from brand to generic by not giving the information to the generic companies. They're not disclosing it like they should. Normally, you have to disclose when your brand is done, all the manufacturing stuff, you're supposed to disclose it. Well, they just delay it and they drag. And Scott Gottlieb, head of the FDA, has basically said, enough is enough. When your patents are over,

you've got to turn all this stuff over. You've got to get the generics going right away. If you drag your feet for a couple of years, it's like having a patent for a few more years. Wow. I didn't even think of that opportunity to screw people harder. And then you get the PBM middle games, which the smoke bomb in the PBM world is the rebates. Rebates are when the PBMs or middlemen,

you name it, any of the middle layers say to the pharma companies, and this is where I have a little sympathy for pharma, if it's okay to say that in America today, the PBMs say, oh, or group purchasing organizations, if you want to be in our catalog, our formularies that we make available to our employees, you know, the benefits programs we manage, or the hospitals that we supply, if we're a group purchasing organization or GPO, pay us a million bucks to be in the

catalog. Well, what does the pharma company do? They pay the million bucks and they build it into the price of the drug. And then the middleman says, hey, this is a good game. How about 2 million? Sure. Build it into the price of the drug. How about 50 million? And we'll give you exclusive placement in the formulary or exclusive placement in our group purchasing catalogs. Numbers directionally. I mean, are you making these numbers up or is that literally what some of the dollar numbers are? It's literally what they are. And not only are they forcing the pharma companies, device companies also are being held hostage, these middlemen, to say, look, you pay us these fees or you're not going to be in our catalog. How do you think we had a shortage of saline?

I mean, ask Jill, who's one of the best nurses I've ever worked with at Hopkins. Ask her, how do we have a shortage of saline? It's salt water. Salt. The two most common elements in the world. Salt and water. How do we have a critical shortage in the price spikes? Why?

Because these middlemen play these play-to-pay fee games called so-called rebates. They're really kickbacks. Let's call it what it is. Let's change the lexicon. Pay us these kickbacks to be in our catalog or pay us a lot of money. You can be the exclusive saline company in our... And then all of a sudden their supply chain gets so thin. I love the notion of there needing to be exclusive saline provider. Like there's something so proprietary about putting sodium in water.

The shiny object they're floating to the hospitals and the employers. Yeah. You're going to get the biggest discount. Oh, we get bulk discounting. Well, you don't even know what the bench reference price is anymore. There's only one company making it. And so they figured out this game. Now the game is very profitable for the, I call it a rich man's game. It's very profitable for everybody. Except the last guy holding the bag. The patient. I mean, the hospitals are even getting a share back sometimes. These reb last guy holding the bag. The patient. I mean, the hospitals are even getting a share back sometimes. These rebates are basically kickbacks. And I've argued to every single politician I get in front of, which is a lot of them. And I could tell you,

I've met with a lot of people in the Trump administration even last week. And I have told them we need to eliminate all kickbacks in health care. It's time we ban all kickbacks. Is that a policy issue? Is that a legal issue? Or is that a market issue? It's two issues. One, it's a policy issue. In 1987, law was passed to give PBMs and GPOs, or it gave PBMs and GPOs, exclusivity so the Sherman Antitrust Act does not apply to this supply chain. I'm glad you bring that up because I was just about to say that sounds like antitrust. Like we certainly wouldn't allow that in any other industry. How bad is it that those middlemen, PBMs, GPOs, have benefited from a law that was passed,

which gave them so-called exclusivity to the Sherman Antitrust Act? It's called the safe harbor. And you'll see a lot of us writing about it. You'll see a lot of it in the policy discussions. Let's get rid of the safe harbor. Let's get rid of kickbacks and health care. Okay. So to fix any problem, you have to immediately understand who's going to be hurt by this situation leaving its status quo. Surely, there must be an army of lobbyists that have no interest in anything you're talking about. They don't want any safe harbors being revoked. They don't want any middlemen going away. And despite the fact that at the individual level, I believe many of these people are disgusted by the profession. In the end,

as a group, you stand up for what you have and you stand up for your livelihood. So it seems to me one of the biggest challenges is, okay, Marty is a voice of opposition to this, but the people who are being hurt the most, which are every human out there, every person in this country, that is, they're not collective. They're sort of like, I'm one guy and I got my bill and I'm getting screwed. And you're one guy and you're fighting with the collections agency and you're one woman and you got breast cancer and you got these guys riding shotgun up your butt and blah, blah, blah, blah, blah. But there's no one that brings them together. So it's sort of like you have an industry complex, a machine that is very easily able to diffuse a bunch of one-off

attacks. That strikes me as to me, the biggest single problem here. It's not the structural problem within the system. There are relatively straightforward ideas that can be tested and iterated on. The problem is how do you create the inertia for change when the people who have to force change at the individual level have less to gain than the collective entity does to lose? That's, I mean, not to be depressing, but that strikes me as the problem here. But the exciting thing is that young people, millennials, doctors, senior physicians that have been in practice who see propofol and sudden shortage, people who understand there's money games and there's stuff that's going on that shouldn't be happening, they're standing up.

They're organizing. I mean, look how- So this has got to be grassroots. I mean, it's grassroots. And you know what's awesome is this is our heritage. This is the medical profession. This is who we are as doctors. We're advocates for our patients. That's who we are. It's in our blood. I mean, when Dr. Sabin invented the polio vaccine, they told him, all his colleagues told him, and these business guys, you need to get a patent on this because this could be the biggest moneymaker in the world.

He said, no, this is the property of humanity. I want as many people to get this as possible. There are estimates of what Salk forfeited by not. $8 billion. Forbes estimated $8 billion of that day. That was 1954, a year when 20,000 people were living in an iron lung machine. You talk about a horrible disease. And he said, this is a gift to mankind. This will be disseminated as broadly as possible.

And it's probably one of the greatest and most inspiring stories. That guy's a hero. That is medicine. That's who we are. I mean, when Benjamin Rush, one of the five physician signers of the Declaration of Independence, had his practice his entire life. He took care of patients with schizophrenia, and he destigmatized mental illness so it wasn't seen as demon possession. His patients were chained to buildings. They had no money. Mental illness meant you were impoverished. He took care of those patients.

He was a role model. He was one of our greatest leaders in society. He was a role model. He was one of our greatest leaders in society. President Adams says, you know, Benjamin Franklin and Dr. Benjamin Rush both had great contributions to mankind, but Benjamin Rush had more, and they were greater. And that's our heritage. I mean, that is who we are. That's who my dad was as he took care of cancer patients.

He's now retired. He would never treat a patient and then destroy their FICA score with surprise bills. We have this incredible heritage of being patient advocates. And if we can channel 1% of the energy we spend on lobbying for higher doctor pay in Washington, D.C. into being the champions of fair and honest, transparent pricing, we're going to see this incredible public trust come back. Because I worry, and I'd love your thoughts on this, but I really worry we are seeing the public trust eroded by this medical money game, billing, predatory game that's going

on. I'm from central Pennsylvania, a town called Danville. The Amish people are very close to that area. We have more Mennonite closer to our region. The Amish people, when someone gets a serious illness, half the time they take an Amtrak train for five days to Mexico because the medical care there has honest and fair, transparent pricing. They're worried about getting price gouged in the hospitals locally. What's that say about our country?

I mean, you get on the Amtrak train in Pittsburgh, where the Amtrak from Lancaster connects with the train that goes cross country. It is mostly Amish people going to Mexico for breast cancer surgery, for a chronic disease therapy, for a medication. What's that say? It says people are hungry for honest and transparent pricing, like Keith Smith has in Oklahoma City. That's what I'm hearing you say is, look, physicians aren't the reason that this system is broken, but now the onus is on them to play a role in catalyzing reform because by association, whether we like it or not, we're now a part of the problem. And it's so proximate to us. We interact all the time. I mean, when I show the egregious

bills or stories of individuals harmed by these bills, or they're paying more on their mortgage because their FICA score was destroyed from a balance bill from an epidural, the hospital executives are very understanding. I mean, they, I think, sometimes just don't know how far the revenue cycle or billing outsourced departments, how aggressive they've gotten. And if you appeal to everyday human instinct, they will say, yeah, this does not seem right. We are very close to our hospital leaders in medicine. We need to say, okay, here's a couple things, a hospital code of conduct. We can get our act together and provide one honest, transparent bill that's not jacked up

for discounts. We can agree we will never sue a patient that's low income and came in for basic medical care. We can agree that if we're going to bill a patient directly, we'll use the Medicare allowable amounts. We're not angry when Medicare pays us. We shouldn't be angry if somebody pays us the Medicare allowable amount. That's a great idea, Marty. Is there such a code of conduct that's being generated and signed off on? This to me sounds like a great first step. There's no order to these steps that can be done in parallel, but I think you could rattle off 10 things that 90% of physicians and hospital administrators would look at and go, yeah, I believe in like everything you just said. Who wouldn't agree to those principles and potentially seven more? Is that in the works? Yeah, my students have put it up at restoringmedicine.org, a basic code of conduct for medical centers. But it's not just

docs. It's not just medical professionals. I have people all the time, everyday folks, if I speak to a conference of, say, real estate agents and we get into all these issues, they'll often say, and I want to do something, what can I do? And I tell them, get involved in your local hospital. It is a community organization. It's a nonprofit with a public mission. And ask these questions. How do you manage patients who can't pay? If their deductible is high and they get a bill or they're uninsured, how do you bill?

What's your average markup? Is it 1.5? Is it 2.5? Is it 23, like we found in some of our research, what is your average markup defined as? How much do you charge above the Medicare allowable amount? We did get the Trump administration. I was very impressed. Seema Verma, Alex Azar, Kelly, I mean, incredible folks that basically said, yeah, we get it when it comes to deferred pricing. We want every hospital to submit their prices. And they did that January 1. It's a first step. It's a first step. These are jacked up prices. We got to get the real prices. But everyday folks want to know what to

do. I tell them, find out what's your hospital's average markup. How do they handle bills that are not paid among low-income insured and uninsured people? Reach out to your local courthouse. Find out if they're suing the socks off of the town, like we've seen in 20% of hospitals in the state of Virginia. And then reach out to your board members and ask them, engage them on the subject. And the hospital board members, it's always the president of the local bank. It's always a couple of business leaders. They're always reasonable people. They come in. I'm on a hospital board. I got a meeting later today at Arundel Medical Center. It's at the big hospital in Annapolis, Maryland. These are good people. Appeal to those people and say, look, we want to take this code of conduct seriously. We

want to be a hospital that provides roughly 6% of our services as charity care disclosed up front to the patient. Not we shake you down whatever, we can't get out of you. Whatever we can't get, we deem charity. We deem charity, which is the standard way of doing business. 6%, charity, honest pricing, honest billing practices. Those are things we can engage our community board members on. That's the purpose of writing this book, The Price We Pay. When you write a book, especially as a doctor, maybe especially even as a surgeon, some people who don't like this message will ascribe to you, and I know you're working on a book. People will ascribe, oh, they're self-promoting. They're just

doing this for self-promotion. What's known among authors is the books don't make money. You don't make them for the time you spend. I mean, I make a lot more money just doing surgery. But this is a way of getting the message out there and to engage people and to say, hey, this is what's happening and this is what we can do about it. Well, Marty, I know you do have to get down to Annapolis today. So I guess we'll bring this to a close. I think there are a lot of things here. It's sort of overwhelming. As I said, I can't really think of a machine that I find more confusing than the U.S. healthcare system. And that in general probably isn't a good thing. I hope that you're right. I mean, I got to be honest with you. I'm concerned

that the force necessary to overcome the inertia is so great that we need a bigger crisis. Because in the end, we'll do things until we can't do them anymore. We always talk about, well, this isn't sustainable. Well, technically it is because we're still doing it, right? What does it take for this to not become sustainable? I don't know. But I love your message that doctors need to sort of get involved in this a little bit because by proxy, we are involved in it, whether we want to be or not. So you take that example of a woman. If you provide care to this woman with breast cancer and you're doing the best you can, and you don't realize that a year later she's getting shaken down for medical bills, well, you can say, well, I didn't have anything to do with that.

And it's true you didn't. But do you also have an obligation to her? And if the answer to that question is yes, then I think that doctors and patients alike can probably overcome what you're describing. I hope that turns out to be the case. I'm seeing some exciting things. I mean, right now, I think the American people are prioritizing this problem as the number one problem in America. When the LA Times reporter, Noam Levy, tells me that more Americans are making different choices at the supermarket. They're cutting their vacations, and they no longer have

money to save for their kids. And sometimes their FICA scores are getting destroyed, all because of surprise medical bills or inflated bills. This is saying, and he's saying, this is going to be the number one issue in the election. This is the number one issue for the American public. And my goal is, how can we educate people? I'm never going to run for office. I mean, I've thought about running for president simply on one issue of banning all plastic surgery. Because I go to Florida a lot, you know, it's the evolutionary reflex of a human being identifying another species and being frightened. You know, like a kid, you know, if a kid sees someone ugly, they don't jump, but if they see someone with all this plastic, they're startled. And it's sort of the natural selection of identifying foreign species.

But this is something that is imminently fixable. We're seeing employers now saying, I want independent brokers and consultants renegotiating my PBMs that don't take kickbacks. There's a group of them. There's not a lot. We put them on the website, Restoring Medicine. Give me all the resources. So where can someone go if they want to know how to find an independent versus a kickback broker? So Health Rosetta is started by

Dave Chase. And what he's done is try to create a brand of sort of the free trade brokers, if you will, that is those people that have agreed to a code of conduct. And it's all transparent. And you feel it's worth getting a second opinion. So that's healthrosetta.com? Health Rosetta. If you Google Health Rosetta, it comes up. We're putting a link to it on our resource, which is- And what's your resource? Restoringmedicine.org. And we're trying to generate some interest.

The students created the website. I put a post on there that showed the prices of everything in America and prices of hospital services, which was crazy off the charts compared to everything else in society. And this thing, I just posted it, got, I don't know, 70 likes in a day or 70 shares in a day. I don't know if I have 70 friends. I realize people are connecting with this issue that we can do better. So that's Restoring Medicine. Restoringmedicine.org basically can point people in the direction of all of the things you're talking about here? Yeah.

And also I've got a website, martymd.com, where I try to provide some resources for folks that are interested in learning more about this. All right. And the price we pay comes out exactly when? They're still floating the date, but it's going to come out when they line it up with the media. But it'll be very soon. All right. Well, Marty, thank you so much, man. Awesome to get to hang with you two days in a row. Great to be with you, Peter. It's just so awesome to see what you're doing,

educating people and promoting good health and re-educating us. And I'd like to see some humility from the American Heart Association just to say, we're sorry. We got it horribly wrong, but I think it's going to be individuals like you that just say, hey, stuff I was taught is now outdated and this is the new science. So thanks for pushing us on that just say, hey, stuff I was taught is now outdated and this is the new science. So thanks for pushing us on that. Well, I'll tell you, that seems like a much easier problem to sort of be working on than the one you're working on. So I think you are actually working on the single most important problem in all of medicine. And I don't say that lightly because I think there are a lot of problems in medicine. But if we don't get this one fixed soon,

we're going to be in, I think, a degree of pain that most people can't fathom from an economic sense. Great to be with you, Peter. Great to see you, man. You can find all of this information and more at peterottiamd.com forward slash podcast. There you'll find the show notes, readings, and links related to this episode. You can also find my blog at peterottiamd.com. Maybe the simplest thing to do is to sign up for my subjectively non-lame once a week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, etc. On social, you can find me on Twitter, Instagram, and Facebook, all with the ID peteratiamd, but usually Twitter is the best

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