Book Review

This Feel-Not-Good Book Must Be Read

Peter Boland

Elisabeth Rosenthal has a unique perspective on what ails the American health care system. She is a physician turned journalist who has some firsthand knowledge about what takes place in American hospitals and doctor’s offices, although her Wikipedia entry makes a point of describing her as a “nonpracticing physician.”

As an award-winning journalist for many years at the New York Times and now editor in chief at Kaiser Health News, Rosenthal has learned the master craft of combining narration with exposition. Animating her book, An American Sickness, is a sense of outrage at what the American health system has become: A source of huge profits and rich compensation for hospitals, doctors, insurers, drug companies, consultants, and countless vendors.

The book was published last year, but An American Sickness should be required reading this year and for many to come for anyone who works in health care or is affected by it, which includes virtually every American. You may not agree with everything Rosenthal has to say, but her book’s relevance cannot be denied,

At the beginning of the book, Rosenthal asks, “Where is all the money going?” in a sector that accounts for 17.9% of GDP and $3.3 trillion in spending. The answer seems to be anybody with any amount of clout in the health care system. Yet Rosenthal argues that we are getting precisely what the current financial incentives demand now that health care is big business. She meticulously explains how these financial rules play out and their terrible effects on the health and finances of patients.

The book is anchored in mini-case studies and poignant stories of people. Rosenthal uses them to illustrate her 10 sarcastic rules of the dysfunctional American health care system:

  1. More treatment is always better. Default to the most expensive option.
  2. A lifetime of treatment is preferable to a cure.
  3. Amenities and marketing matter more than good care.
  4. As technologies age, prices can rise rather than fall.
  5. There is no free choice. Patients are stuck. And they’re stuck buying American.
  6. More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
  7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
  8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
  9. There are no standards for billing. There’s money to be made in billing for anything and everything.
  10. Prices will rise to whatever the market will bear.

This is a harsh list. Unfortunately, it rings true.

Rosenthal ends her book with a call to action to take on the health care system. Her prescription includes dozens of recommendations on consumer actions, financial incentives, and policy initiatives. It places a heavy burden on patients as change agents. Some reviewers have questioned whether patients should be demanding answers from their doctors about cost and coverage, as Rosenthal suggests, or whether it would be smarter to go to an administrator for that kind of information.

The mission of the book is to advocate for a return to a system of affordable, evidence-based, patient-centered care. But rather than idealizing another era, it would be more fruitful to advocate for new business models with financial incentives that result in lower costs, better care, and more patient engagement.

Juliet Eilperin, the senior affairs correspondent for the Washington Post, wrote last year that Rosenthal has produced a “fairly grim tale” about how patients (and insurers) are getting ripped off by the health care system. “In short, this is the antithesis of a feel-good book,” zinged Eilperin.

But An American Sickness is an important, clear-eyed look at our health care system. It lays bare jargon that inhibits understanding and patient engagement. The book is controversial—sometimes in tone, sometimes in substance—but not gratuitously so. And it is a reminder of how much more work needs to be done to make business-driven American health care accessible and affordable for patients and working families.

Peter Boland of Boland Healthcare is a health care management consultant in Berkeley, Calif., and a member of Managed Care’s editorial advisory board.

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