An American Sickness: How Healthcare Became Big Business and How You Can Take It Back

Book Title: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back

Book Author: Elisabeth Rosenthal

Publication Information: New York, Penguin Press, 2017, 432 pp., $18, paperback

Elisabeth Rosenthal, MD, is a Harvard-educated, New York Hospital-Cornell Medical Center-trained internal medicine doctor who has spent the last 22 years reporting about, rather than practicing medicine. While her career as a reporter for the New York Times took her initially to China and subsequently to Rome, her focus turned back to health care in 2012 when she became a health care correspondent covering the Affordable Care Act (ACA). In 2016 she joined the Kaiser Family Foundation as Editor-in-Chief of the Kaiser Health News. As a skilled reporter with a medical background, she is well qualified to dissect and interpret the American health care system, and this is the intent of An American Sickness.

An American Sickness is organized like a medical SOAP (subjective, objective, assessment, and plan) note—the first half of the book focuses on the history of the current state of unaffordable medical care (the “history of present illness and review of systems”) and the second half suggests opportunities for patients and the system to “take back health care” and reduce costs (the “diagnosis and treatment” section). In the first half of the book, Dr Rosenthal leaves no stone unturned—reviewing the history and cost implications of all aspects of the current care delivery system: insurance, hospitals, physicians, pharmaceuticals, medical device companies, ancillary services, billing contractors, and for-profit research. The first half ends with a review of the current state of medicine: the ACA, health care conglomerates, and the age of health care as a pure business.

By the middle of the book, even a nonmedical reader will begin to appreciate the complexities and implications of how the system became what it currently is. For physicians, while much is familiar (like the role of pharmaceutical representatives and insurance authorizations), having the entire history laid out starkly and succinctly might lead even the most adamant free market capitalist-supporting physician to question the sense of how things are currently constructed. While the second half of the book mostly gives patients a how-to manual for understanding all their costs (doctors, hospitals, insurance, drugs, etc), it includes suggestions on how to improve the systemic issues of each domain. Finally she adds five appendices for patients to price shop, understand if a test is necessary, and even to appeal or protest a bill.

Overall, the book is easy to read, factual and well sourced, and very thorough. Most physicians will likely find the diagnosis section most interesting, pertinent, and relatable. Any doctor who has spent an hour fighting an insurance company for a prior authorization will be able to relate to the many examples of frustrated patients in the stories. The solutions in the diagnosis and treatment section, while containing many well reasoned and good ideas, may not be politically attainable or agreed on by all physicians. Nevertheless, there are a few take-home messages all medical educators should think about. The first is individual awareness. All of us should strive to provide evidence-based medicine, be aware of the Choosing Wisely initiatives (www.choosingwisely.org), and avoid payment conflicts by not accepting pharmaceutical payments or self-referrals. We all need to model solutions, not problems. Next, we need to be familiar enough with the complex system in which we work so that we can teach the principles of cost-conscious care to the students and residents we educate. If we do not explicitly have cost curricula, we need to be sure to incorporate the concepts into daily teaching rounds or patient encounters. Otherwise we are doing a disservice to the next generation of physicians. Finally, all physicians need to be engaged advocates for high-quality, lower-cost care on behalf of ourselves and our patients. Our current system is not sustainable on its current trajectory, and we need to be active participants in creating solutions, not just passive observers. Picking up and reading An American Sickness—and potentially using it as part of a journal club on cost of care and systems-based practice learning in your residency program—is a good start for everyone.