By MARC-DAVID MUNK
In our palliative medicine clinic in the working suburbs of Boston, my colleagues and I tend to some of the sickest patients in the city. Through the window, I can see the afflicted pull up to our squat building in family sedans, wheelchair vans, and subsidized municipal ride cars. Few drive themselves: most bear terrible illnesses that make them too frail or sedated. I watch as patients who are barely able to dress themselves, somehow arrive in their Sunday best for clinic.
Our job, as their doctors, is to manage their pain and provide moral support and practical help with things such as rent and transportation, sometimes spiritual support too. It’s important work, among the highest callings in medicine. Yet, as noble as this work might be, our clinic doesn’t begin to support itself financially. If there was ever a reason to spend graciously on patients and their needs, these visits, with their sick and vulnerable patients, would be exemplars. In fact, we don’t receive enough payment from insurers to cover the costs of the complicated work that’s needed. Practically, this translates to few staff to help with appointments, not enough follow-up calls, nobody to help with insurance headaches or pharmacy shortages, nobody answering the phone. Our facilities are tired. The simplest niceties—coffee in the waiting room, magazines, a comfortable chair—are long gone.
There is a feeling of “meagerness” in the air. It’s the feeling of being rationed. It’s an absence of all but the truly essential; no plenitude, a lack of graciousness. I see meagerness when my friend, an emergency physician at a major trauma center, shares pictures of his decomposing ER: desk chairs held together with medical tape, rooms without functioning equipment. Medical supplies that are so scarce that doctors keep stashes in their desks and coat pockets.
The administrators will say that these barren conditions are a consequence of financial scarcity. There isn’t enough money to pay for more than skeleton support and upkeep. Hospitals are running deficits and downsizing. Keeping the lights on is apparently a question of saving pennies at every opportunity. And, with every cut, meagerness grows. This all sounds, on its surface, understandable till you take a step back and realize it isn’t. We know that American healthcare consumes more money than any other country, per capita. Money is pouring, truly flooding, into our healthcare system. Family health insurance premiums rose 7% from 2023, after another 7% increase the year before. The average family policy now costs around $25,000 per year.
Which leaves me wanting to reconcile how there can be so much money entering the system, with so little left for essential front-line care. I know that this isn’t a complicated answer.
My fifteen years spent as a healthcare administrator, negotiating with payers and suppliers, has taught me that our societal healthcare money has, simply, been diverted, tapped out. Intermediary costs, across a broad healthcare landscape, have become so extreme, so unregulated, so usurious, that there is only a trickle left to deliver anything but the most miserly front-line care.
Here in America, we specialize in allowing thousands of organizations, many found nowhere else in the world, to pass on unheard-of costs to, well, ourselves. We have group purchasing organizations (GPOs) and accountable care organizations (ACOs). There are medical service organizations (MSOs) and physician organizations (POs). Also managed care organizations (MCOs) and health maintenance organizations (HMOs). Physician-hospital organizations (PHOs) need to be paid for, too. There are contracting offices, coding offices, compliance offices, credentialing offices, case management offices and claims processing offices. Many organizations exist to provide push for one outcome; others exist to push for the opposite. All are costs.
Our six largest health insurers together have revenue that would make them the 14th largest GDP in the world if they were a country, smaller than Spain but bigger than Australia. They typically spend around eighty-five percent of what they collect on medical care… the rest is their overhead and profit. The United States spent almost twice as much as other high-income countries on care, driven by labor, pharmaceuticals and devices, and administrative costs. Drug manufacturers charge Americans multiples more than other countries for identical medicines. Prices for cardiac implant devices are multiples higher in the US than in Germany. Hip implants in the US are multiples more than those in Canada. Malpractice insurance is crushing, with some doctors paying hundreds of thousands annually for liability coverage. Electronic medical records cost hospitals up to hundreds of millions of dollars to install.
Here, regulatory agencies have made themselves both expensive and indispensable. The American Board of Internal Medicine brought in $90 million in fees in 2023 (and there are 23 other specialty boards). The Joint Commission pulled in $208 million last year. Press Ganey, which owns a large part of the mandatory patient survey business, reportedly had revenues in the hundreds of millions of dollars (before they stopped reporting revenue figures after being bought by private equity). The medical journal business is especially galling: doctors write, edit, and review articles for free, yet those journals are locked behind paywalls. Elsevier’s parent company, with over 2,500 journals, generated £3.06 billion in revenue in 2023 with a 38% profit margin.
Good luck saying no to all this. We’re stuck. Doctors have no choice but to be board certified. Hospitals must be surveyed. Expensive licenses and permits are non-negotiable. We pay what they ask, with increases year after year. On these cocooned organizations, we impose few demands, few hard bargains and few consequences for poor value. In my early years in medicine it felt like there was at least a veneer of plentitude. These days, I look at our worn clinic and our patients who respond with dignity as I explain that their insurer has rejected their fifteen-dollar pain medication prescription, again.
I wonder when we will admit that we are at a point where–through regulation and administrative gaming, policy contortions and oligopolist behavior—the opportunists have finally killed the golden goose. I wonder when, in an environment of clinician fortitude and heroic commitment to patients, we will know that we have reached a tipping point where it’s no longer an environment of meagerness but one of privation, where balls are dropped and people truly suffer.
With so many entrenched interests, it’s hard to imagine how this gets resolved. For thousands of years, when it has mattered most, there has been no substitute for the work of a doctor caring for a patient, one-on-one. There still isn’t. But, around the best parts of American medicine we have settled for a Rube Goldberg-like apparatus that functions mostly to perpetuate itself. It extracts real tolls from real people. It’s uniquely repugnant, uniquely absurd, uniquely American.
Marc-David Munk is an academic palliative medicine physician, and a former healthcare executive at several private and VC-backed value-based healthcare delivery organizations.
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