A conversation about Health Policy with Elizabeth Rosenthal


The acclaimed author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” physician, and now Editor-in-Chief of Kaiser Health News, Dr. Elizabeth Rosenthal speaks to me about health policy and how it has changed over time.

Listen to our conversation at Radiology Firing Line Podcast.

About the author:

Saurabh Jha is a contributing editor to THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner

7 replies »

  1. Just think of the behavioral economics involved. How many insurance companies or hospitals would want their ridiculous payment or pricing strategies on the front page of the WSJ? I have often thought that if we could cluster a group of behavioral economists at a hotel “annually” for 1 week, they would solve the social dilemma of our nation’s excessive level of health spending within 5 years. Nobel honoree Richard H. Thaler (MISBEHAVING, 2015) and 4 others of his choosing comes to mind along with Ben Carson, M.D. as its Co-Chairman. Maybe the Aspen Institute folks could organize it and arrange for its funding. Location…hmmmm….how about Camp David.

  2. I am reminded, again, of the unusual business model for Pharma. 60% of their cash revenue is allocated to research and production expenses. The remainder is allocated to profit and promotion (aka, advertising). Their business model and its odd manifestations, especially around market share manipulation, are focused to sustain their stock market based corporate worth. Their Social Responsibility duties would be difficult to identify. But, as a portion of our nation’s health spending, its net increase has been steady at about 11%. Over-all, our nation’s health spending as a portion of our national economy (aka GDP) has increased from 5% in 1969 to 18% in 2016.

    I would estimate that about 60% of our nation’s citizens survive with a minimal level of disposable cash (such as the equivalent of 3 months of income) as a basis to withstand a sudden major healthcare expense. Historically, It represents the most common basis for personal bankruptcy. The lack of protection from sudden expenses for a family may be a major cause of an unwillingness to maintain stable health for long period of time. The severity of a catastrophe for a person with marginally stable health may be an underlying cause for a portion of our nation’ very high level of health spending. A family health insurance policy with a maximum out-of-pocket limit of $4,000.00 is ridiculous.

  3. I also think it would be useful if each state had an expedited arbitration procedure to resolve medical billing disputes between payers and providers. The process should use so-called baseball arbitration where the arbitrator chooses one side’s position or the other rather a split the difference approach.

    If the dispute is between an uninsured patient and a provider, especially a hospital, the arbitrator could have the flexibility to use some reasonable percentage of Medicare combined with the patient’s ability to pay based on tax returns and other documentation.

    Drug prices might have to be tackled in a different way perhaps through a combination of partially lifting import restrictions and a greater willingness to just say no to coverage in some cases.

  4. I’ve said many times that there needs to be special rules that govern how much hospitals, doctors and other providers can charge for care that must be delivered under emergency conditions. If it were up to me, that number would be 125% of Medicare though 150% might still be within the zone of reasonableness.

    When patients receive huge unforeseen bills for out-of-network care in a hospital, I don’t see how such claims can be enforceable when there was never a meeting of the minds on price. Signing a financial responsibility form under duress is not enforceable consent to pay.

    Even for in network care, payers should be negotiating reimbursement rates that are up from Medicare, not down from chargemaster prices. If one hospital charges 5-6 times what another nearby hospital charges and manages to collect that sum from an insurance company, maybe hospitals deserve to be regulated like utilities.

    There are thousands of drugs available for patients to take. Roughly 90% of prescriptions are now for generic drugs and there is plenty of competition for most of them. When one of my drugs, Plavix, went off patient, the price for a 90 day supply dropped from $546 to $25 overnight. It’s about $40 or so today, still quite reasonable. The prices of my other five generic drugs have all gone up over the last six years or so but not egregiously.

    By the way, PBM’s exert at least some price discipline on drug companies through rebates and formulary placement. If PBM’s didn’t exist, drug companies would be free to raise prices often and aggressively with no check on them short of payers refusing to cover the drug at all.

  5. Once again we are faced with the realities of pricing and reimbursement strategies within our nation’s healthcare industry. So how is it that this institutional “co-dependent” relationship has evolved as it has? I offer a quotation from a book written by Elinor Ostrom and published in 2005: UNDERSTANDING INSTITUTIONAL DIVERSITY. From the first page, here is her definition of an institution.
    “…the rules that humans use to organize all forms of repetitive and structured interactions including within families, neighborhoods, markets, firms, sports leagues, churches, private associations, and governments at all scales. Individuals interacting within rule-structured situations face choices regarding the actions and strategies they may take, leading to consequences for themselves and for others. The opportunities and constraints individuals face in any particular situation, the information they obtain or are excluded from, and how they reason about the situation are all affected by the rules or absence of rules that structure the situation. Further, the rules affecting one situation are themselves crafted by individuals interacting in deeper level situations. For example, the rules we use when driving to work every day were themselves crafted by officials acting within collective-choice rules used to structure their deliberations and decisions. If the individuals who are crafting and modifying the rules do not understand how a particular combination of rules affect actions and outcomes in a particular ecological and cultural environment, rule changes may produce unexpected and, at times, disastrous outcomes.” Read it again, once or twice, to understand its relevance for healthcare reform.

    Nearly 300 years ago, President Thomas Jefferson spoke similarly about the basis of institutional change. The brief essay is chiseled in his memorial on the tidal basin in Washington, D.C. Its last two words are “…barbarous ancestors.” See URL below for full citation.