Makary Calls for Price Reform, Transparency to Fulfill Patient-Centered Medical Heritage

Marty Makary, MD, MPH, chief of the Johns Hopkins Islet Transplant Center, kicked off the Academy of Managed Care Pharmacy (AMCP) Nexus 2020 meeting with a call to action around reducing overprescribing, increasing price transparency, making medical billing practices fairer, and recapturing the public’s trust in the health care system.

Makary began his presentation with a drawing of what he calls his favorite organ: the human appendix. Recent research on appendicitis has yielded findings that surgery is not the best option for all patients and 75% of simple appendicitis cases can be treated effectively with antibiotics alone, exemplifying the ongoing pursuit of precision medicine approaches that determine which interventions will benefit specific patients instead of reflexively pairing diseases with treatments.

However, the intervention that gets the least attention is lifestyle change, Makary said, and he called for an honest conversation around why research on these issues has not been funded, there is no National Institutes of Health division on lifestyle, and there are few outlets to publish studies on behavior change. He cited a 17-year lag between discovery and clinical adoption of a best practice as an example of how the health care system is slow to embrace new evidence.

“So we have this system that is littered with a lot of practice variation, some of which is entirely unwarranted and wasteful,” Makary said.

He highlighted the “crisis of appropriateness” that has developed as new prescriptions have nearly doubled in the past 10 years, all the while there is little discussion on how hypertension may be treated with stress management instead of medications or diabetes can be addressed with cooking classes instead of insulin. Sleep quality and general body inflammation are just starting to become more prominent in the conversation around one’s health.

The overprescribing crisis is important to address with humility, said Makary, admitting that he had overprescribed opioids for most of his career “with good intentions and bad science.” He cited an experiment that addressed letters to Mohs surgeons who removed an above-average number of slices of tissue per surgery. They are paid per block of tissue, creating a perverse incentive to remove more, but the letter highlighting their outlier status was effective in getting 83% of them to reduce their practice patterns, resulting in $21 million in savings to CMS.

Outliers are not bad physicians, Makary argued, but they need help. He highlighted a simple source of this help: listening to the providers on the front lines, like pharmacists, who raised alarms about the burgeoning opioid crisis long before the problem was widely recognized.

He also praised the work of new primary care clinics like Iora Health, ChenMed, and Oak Street Health that have begun to enter low-income communities by telling Medicare “let us just be a great clinic and get us off of the billing/throughput/preauthorization cycle and just let us take care of a population.” Part of their success is that they dispense medications in the clinic and recognize that pharmacists should be embedded in the clinical team, not seen as a separate branch. Their clinical teams are made up of physicians, pharmacists, nurses, administrators, and health coaches who hail from a variety of academic backgrounds but all have the common value of empathy.

Makary spoke of his father, a hematologist who treated patients alongside a clinical pharmacist who eventually became his closest friend, and how the duo treated patients together for decades, exemplifying the “incredible teamwork that is American medicine.”

“Even though we may spar on different payment models, what attracts everybody at every level to health care is a sense of compassion,” Makary said. “That’s what unites us all.”

Another uniting factor, albeit a less positive one, is the understandable frustration that patients have with the inscrutable health care pricing system. Just as shoppers can view and compare prices before purchasing a flight, they should be able to do so with health care, Makary said. He pointed out that Tim Xu, MD, MPP, a coauthor with Makary of a paper on emergency department excess charges, is a “genius,” but even he could not figure out the “unbelievably complicated” system of hospital billing markups.

Makary called out the practice of hospitals suing patients and garnishing their wages to pay for unaffordable bills, which he said “violates everything sacred about the doctor-patient relationship.”

He called for greater public accountability by listing hospitals’ billing practices and average price markups in search results, as well as for financial toxicity to be measured as a medical complication like infection or readmission. With these steps, and the growth of new primary care clinics like ChenMed that aim to combat loneliness by building relationships with patients, we can get out of the billing/throughput cycle, end the game of marking up services, and instead reinvent health care, Makary said.

American hospitals were built with a charter to care for all patients, as part of our “great medical heritage,” Makary explained, and rather than assigning blame for today’s broken health care system, stakeholders need to unite around the common goal of healing patients and redesigning health care from scratch. New platforms like podcasts and blogs can help disseminate information more quickly to patients and clinicians, as opposed to the slow process of publication in medical journals.

“We can do better with [coronavirus disease 2019]; we can do better in many situations in health care today. If you think about our great medical heritage, it’s one of putting patients at the center of the system,” Makary said.

In response to a question posed by Susan Cantrell, CEO of AMCP, about what pharmacists and health plans can do to recapture public trust, Makary encouraged individual clinicians to speak up to their organizations about high health care charges. He also noted that outside of the “echo chambers” of cable news and social media, there is broad consensus around many of today’s health care issues, such as increasing the appropriateness of care and funding research on a proactive health care system that is more resilient for health emergencies, where “we can focus on what we have in common.”