The official estimate of total healthcare spending in the United States is given by the National Health Expenditure Accounts (NHEA), which assesses annual U.S. expenditures for healthcare goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care. According to the NHEA, healthcare spending in 2020 was $4.1 trillion or $12,530 per person. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7 percent[1], more than the GDPs of Brazil, the U.K., Mexico, Spain, and Canada.

The United States Census Bureau reports that 8.6 percent of people, or 28 million, did not have health insurance at any point during the year.[2] The underinsured are defined as having high health plan deductibles and out-of-pocket medical expenses relative to their income and are thus more likely to struggle to pay medical bills or to skip care because of cost. Among adults who were insured all year, 29 percent were underinsured in 2018[3], probably an unreliable number since the definition of “underinsured” is subjective.

When I delivered the above statistics to a conference on health care at the Lutheran church my wife attends, the congregation of mainly retirees split into two opposed groups, roughly equal, each citing Jesus. The members of one group shrugged their shoulders and agreed that the poor will always be with us, alluding to Matthew 26:11. The other followers of Jesus moaned, expressed guilt, and paraphrased Matthew 25:40, “What you have done to the least among me, you have done to me.”

Each group pressed me for my opinion, but acting as a seminar leader, I refused their request and asked them a series of questions. Their answers revealed that the high cost of health care was not their major concern; virtually every professional, retired or not, is well-insured. The main complaint I heard was that over the last twenty years, hospitals and doctor’s offices had become more and more impersonal; most claimed this was not nostalgia for the old-time family physician who served everyone in a small Midwestern town. I came away from the conference convinced that the other healthcare crisis is that patients have become numbers bounced from one specialist to another, with no one doctor overseeing a patient’s care. I knew exactly what the conferees complained about.

Navigating the Healthcare System

Clearing the Low Bar

Five weeks ago, I developed a rash on my chest and back, a rash that at first was a mere annoyance and that I attributed to an allergy from my intensive weed whacking. The unusually heavy rain in Santa Fe this summer produced an extensive crop of strange weeds, an anomaly in the high desert. In midsummer, while shopping at Whole Foods, the yearly monsoons began, and several young people ran out into the parking lot and danced, but with every good thing comes a curse, according to Sophocles.

I thought my rash would soon disappear, but in two weeks, the itching was unbearable, especially at night, and my home remedies — hydrocortisone and CeraVe — were ineffective, so I was not sleeping more than four hours a night. Out of desperation, I booked an online appointment for 9:00 AM at Presbyterian Urgent Care.

At 9:10 AM, Dr. Skinner[4], who looked like he just got out of medical school, walked into the examining room, introduced himself, and told me he was not a morning person. He went on to inform me that doctors and patients seldom discover the source of a rash. I pulled off my shirt, and Dr. Skinner, with blue rubber gloves on his hands, carefully examined the red blotches and raised bumps on my chest and back. Then, he made what I then thought out of my ignorance was a perceptive observation; the rash was not below my beltline. His diagnosis was contact dermatitis, and the treatment was to launder all my clothes, including bedsheets, in Dreft baby detergent and to shower with Dove sensitive skin soap. In addition, he prescribed 10 MG of prednisone a day for five days, with the caveat that prednisone destroys the body, but short-term use is okay.

Two weeks later, the rash had not subsided, and the effects of the prednisone were gone, so the itching returned with a vengeance. I went to my dermatologist’s office, guessing that a request for an appointment would be harder to turn down if I were face-to-face with the receptionist. I seldom look at a calendar, and was surprised that it was Columbus Day, now called Indigenous Peoples’ Day; nothing stays fixed in America, not even names; janitors became custodians; maids morphed into members of the housekeeping staff, and I standing in the dermatologist’s office was not a patient, but a client.

The receptionist told me that no medical personnel would be in the office for a week and that Dr. Reichenbach could not see me until the end of February. Hope had clouded my reason. I knew ahead of time that Dr. Reichenbach would not see me; much as I liked him — over his desk in an elegant frame hung the key sentence from his favorite movie The Magnificent Seven, “It seemed to be a good idea at the time”— he rushed patients in and out of his office, accruing large sums of money to pay two alimonies, or so I assumed.

I told the pleasant receptionist, a young woman dressed in a red dress, that I would be in a psychiatric ward by February; I needed immediate medical treatment. She suggested that I go to the dermatology clinic at CHRISTUS St. Vincent Hospital, only one mile away.

The receptionist at the clinic, an overweight woman in her fifties, dressed in black, told me, “We do not take walk-ins.”

I explained that this was a medical emergency.

She twisted up her nose and said, “Everyone says that.”

If it weren’t for my good Romanian upbringing that instilled in me that I should treat everyone with respect, I would have flipped her the bird and walked out. Instead, I said, “Some people do have medical emergencies.”

With great effort and annoyance, she got up from her Herman Miller chair to go ask the doctor if he would see me. She returned and said, “The doctor suggests that you go to the ER.”

I told her the emergency room would do me no good since, generally, no dermatologist is on duty.

I noticed that the waiting room was empty, and I concluded that the doctor referring me to the ER was his way of flipping me the bird; he did not want anyone interrupting his easy routine. I, of course, was offered an appointment as a new patient at the end of January. For all I knew, the doctor was in his office playing video games on his laptop.

I sat in my parked car, trying to understand the runaround I had experienced. I lived in Santa Fe for decades and recalled that the old St. Vincent Hospital was downtown and run by mean nuns who looked you straight in the eye and told you what you could not do. My son was born at St. Vincent’s, and the nuns combined his long, black hair in the style of Adolph Hitler.

In the new St. Vincent’s Hospital, the nuns and the crucifixes were gone. The hospital is now owned by CHRISTUS Health, a corporation that owns 60 hospitals and 175 clinics, mainly in Texas, Arkansas, Louisiana, Georgia, and New Mexico. The name CHRISTUS, a relic from the past, perhaps a marketing tool now, did not accord with the dismissive reception that I received. I doubted that any of the doctors or staff had read the mission statement of CHRISTUS: “To extend the healing ministry of Jesus Christ.”[5] I don’t think Jesus would turn away the sick, schedule doctors fifteen minutes per client, or aim to increase the bottom line. Nor do I believe he would direct CHRISTUS to increase their profits by buying up medical practices, imagining centers, and pharmacies. Hospitals across the country are rolling in cash; nominally non-profits, the money must be spent. CHRISTUS St. Vincent Hospital spent its excess cash not on reducing patient cost but on renovations to the plant facility and on converting wards and double rooms to single rooms.

CHRISTUS, like most corporate health care in the country, applies business practices to restrain expenses and increase efficiency. “Price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement,” according to Pamela Hartzband and Jerome Groopman, both M.D.s at Beth Israel Deaconess Medical Center in Boston. “Physicians are now routinely provided with profit-and-loss reports reflecting their activity, and metrics are calculated to measure the cost-effectiveness of their work.” Not surprisingly, they report, “Many physicians we know are so alienated and angered by the relentless pricing of their day that they wind up having no desire to do more than the minimum required for the financial bottom line.”[6] In the business model of health care, no metric measures the personal aspect of medicine.

Caught in the corporate healthcare system, I went back to Presbyterian Urgent Care. I saw a woman physician in her late fifties, bright, bubbly, and friendly but with the prior diagnosis, contact dermatitis. The prednisone was increased to 20 MG per day for seven days. I finally caught on; medical students take two hours of dermatology and learn about one disease, contact dermatitis. With my experience, I figured I could work part-time at Presbyterian Urgent Care diagnosing skin disorders.

Back in the car, my next plan was to call a psychiatrist friend of mine; she loves to intervene in the insane healthcare system. But before calling her, I had one last hope. More than ten years ago, I went to Beth Peterson, then a new dermatologist in town, for a minor skin problem. If I now returned to her office, I was afraid that I would be thrown out for showing up every ten years. Instead, the two woman receptionists greeted with a cheerful good morning. Within fifteen minutes, I was in the examining room, explaining my condition to Mary Ann Forest, a very young PA.

She took one look at my rash, diagnosed it as a drug allergy, biopsied a patch on my back, injected me with prednisone, prescribed an anti-itch cream; and we chatted. She had been at Presbyterian Medical Services, hated the excessive regulations and rules, and quit to join Dr. Peterson’s medical practice. I told her thank god for the mom-and-pop medical care. I had my blood pressure medication changed, and the rash disappeared.

Clearing the High Bar

Five years ago, my older daughter, Tanya, was diagnosed with breast cancer, the first major illness in our nuclear family. At first, I was so distraught that I could not think rationally. Sharing Tanya’s anxiety and fear allowed me to commiserate with her but made me worthless in assessing her cancer treatment. For her welfare, I forced myself to push my emotions aside. I now understand why the average person goes to an oncologist, perhaps one recommended by the surgeon or a friend, and sits there like a dummy, effecting saying, do to me what you think is best. The nearness of death overwhelms all of us.

Tanya lives in Charlottesville, Virginia, and her primary care provider directed her to Dr. Heller, an oncological surgeon at the University of Virginia Hospital. I thought he was an excellent surgeon, although a poor communicator, and, of course, he wanted to try new techniques, such as saving Tanya’s nipple and recommending special restoration surgery. After three weeks of consultation with a cosmetic surgeon and Tanya, he decided that this extra surgery would fail. One look at Tanya, who is extraordinarily small, weighing less than one hundred pounds, would tell a reasonable, non-medical person that such procedures made no sense.

Tanya’s healed quickly from her mastectomy. One sentential node had micrometastasis; instead of further surgery to remove more lymph nodes, Dr. Heller suggested radiation therapy; in this way, the risk of lymphedema was negligible.

The University of Virginia Cancer Center assigned Tanya to an oncologist, the wife of her oncological surgeon. A very bad idea because in discussing Tanya’s cancer treatment, her oncologist and her husband must also have had complex interspousal dynamics at play.

The oncologist suggested that Tanya have the Oncogene DX type test done, to which Tanya agreed. This was a clinical trial to determine which breast cancer patients were overtreated with chemotherapy. Tanya’s score was eight, meaning she was at very low risk for her cancer to recur. Given this score, the question then became what the best cancer treatment for Tanya was, tamoxifen alone or tamoxifen and chemotherapy. The data from the Oncogene DX type trial indicated that the benefits from tamoxifen alone or tamoxifen and chemotherapy were about equal. At this point, Tanya’s oncologist leaned toward tamoxifen and chemotherapy, but not heavily.

I arranged for a second opinion from Johns Hopkins. At first, the oncologist there also leaned toward tamoxifen and chemotherapy. But a few days later, she had second thoughts. She had the pathology of Tanya’s tumor redone, and the pathologists at Johns Hopkins used a microscopic analysis and concluded that the size of the invasive tumor was .8 cm, not the 1.8 cm that the gross analysis of the UVA pathologists gave. I knew that pathology depends heavily upon judgment and is not like a chemical assay that gives unequivocal results.

The oncologist at Johns Hopkins consulted seven other oncologists there, and they unanimously agreed that Tanya should have radiation and tamoxifen but no chemotherapy. They argued that the benefits of chemotherapy are 1 to 2 percent, and the harm of chemotherapy — heart damage and leukemia — are 1 to 2 percent. This correct way of assessing low risk means that chemotherapy was not indicated.

The oncologist at UVA was miffed that Tanya got a second opinion; she would not have the pathology redone and brushed off the recommendation from Johns Hopkins as an annoyance. She changed her medical assessment and insisted that Tanya get chemotherapy; otherwise, she would be “playing games with her life.” The resident in her office told Tanya, “Think of your ten-year-old son. He would look at you and say mommy, I want you to be alive in ten years, so please do everything you can to stay alive.” The resident pulled up numbers from the Internet that said that with tamoxifen alone, the breast cancer recurrence rate for Tanya was 16 percent and with tamoxifen and chemotherapy, the rate was 8 percent. This was the very first time these numbers appeared. In my mind, the oncologist and her resident were using every trick to manipulate Tanya into agreeing to do chemotherapy.

The numbers for recurrence of 16 percent and 8 percent appeared late in the game and at best came from computer modeling, not actual data. (It is not clear that the resident put the correct data into the computer program; I got different numbers for recurrence than she did.) The oncologist at Johns Hopkins, also a woman, told me in an email that she did not put much credence in such numbers, and rightly so. Such computer modeling is notoriously wrong; think of the computer models that theoretical physicists developed for financial risk. Such models nearly sank the economy in 2008 because bank CEOs and hedge fund managers did not understand the limits of computer models, and many physicians do not either.

Most people, including many physicians and counselors, do not know how to assess risk. Tanya was repeatedly told that she had to do everything she could, including undergoing chemotherapy. “Do everything you can do” seems right until you think about it. If the potential benefit of chemo is 5 percent and the potential harm is 15 percent, then clearly to do everything you can is foolish, if not downright stupid, but that is the camp that the UVA oncologist fell into, and furthermore, she wanted to use the most toxic chemo available for the same reason.

The next day, at my insistence, the oncologist from Johns Hopkins called the one at UVA; unsurprisingly, the UVA oncologist held her ground and refused to listen to any outside opinion. She never told Tanya that she talked with the oncologist from Johns Hopkins.

I convinced Tanya that the UVA oncologist was arrogant and refused to listen to her patients or to oncologists outside of UVA. Furthermore, she was not interested in Tanya’s well-being; she, for some reason, was mainly interested in getting Tanya in a clinical trial as another data point. The Oncogene DX Trial needed women with a low risk of breast cancer recurring who received tamoxifen and chemo.

The oncologist at Johns Hopkins spent two hours with Tanya, and later many more hours reviewing and thinking about her case and exchanging numerous emails with me. I am convinced that the UVA oncologist mindlessly read Tanya’s pathology and test results as if she were reading a checklist. She was always in a hurry, and all her visits with Tanya added up to at most 45 minutes.

In seeking the best cancer treatment for Tanya, I ran into three problems that plague all human life. 1) Ego: The UVA oncologist, like many physicians, does not like to be challenged by patients or outside experts; 2) Ignorance: I hate to appear cynical, but most people, including many experts, mechanically follow the rules of their discipline without really understanding the underlying principles and the limitations of certain established procedures; and 3) Delusion: We desire absolute certainty and a world without risk, and think that the impossible is possible. But our lives and nature are permeated with contingency and chance. Certainty is impossible, and risk can never be reduced to zero. At best, we can try to negotiate our way through the world intelligently, realizing that we may fail. Covid-19 convinced most of us that life is not predictable like Newtonian physics.

To clear the high bar of cancer treatment, I encountered many knowledgeable and compassionate doctors; one oncologist, a woman with two young children, told me that for her medicine is not a job but a calling. I also had run-ins with sloppy and indifferent doctors. From my own personal, admittedly narrow, experience, money has always been part of medicine, but not the primary motivation of most doctors. I guessed that with the increasing presence of the corporate model of health care, more young doctors were choosing lucrative specialties, such as anesthesiology, radiology, and ophthalmology, that can be practiced during regular, limited work hours.[7]

In America, a person with cancer can get the best treatment in the world at Johns Hopkins, MD Anderson, and Sloan Kettering provided he or she has excellent insurance and is persistent or has a family member or friend who is. I have dealt with doctors and staff members from all three of these cancer centers, and everyone was helpful, knowledgeable, and even compassionate.

I was able to successfully clear the high bar of cancer treatment for my daughter because I have a Ph.D. in theoretical physics; I grew up reading graphs, assessing data, and challenging authority. With the increasing presence of the business model in health care, the poor and the uneducated accept what is thrust upon them and are becoming more and more victims of modern health care that is meant to serve them.

Endnotes

[1] For United States healthcare expenditure data, see the Centers for Medicare & Medicaid Services, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.

[2] Congressional Budget Office, “Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026,” https://www.cbo.gov/publication/51385.

[3] The Commonwealth Fund, “Underinsured Rate Rose From 2014-2018, With Greatest Growth Among People in Employer Health Plans,” https://www.commonwealthfund.org/press-release/2019/underinsured-rate-rose-2014-2018-greatest-growth-among-people-employer-health.

[4] The names of all the physicians have been changed.

[5] CHRISTUS Health Mission Statement, https://www.christushealth.org/about/our-mission-values-and-vision.

[6] Pamela Hartzband and Jerome Groopman, “Money and the Changing Culture of Medicine,” The New England Journal of Medicine 360 (January 8, 2009): 101-103.

[7] See Hartzband and Groopman.