Abstract
John Kellum is a distinguished professor of Critical Care Medicine at the University of Pittsburgh; has an endowed research chair; has practiced clinically for over 30 years, and is world renowned in critical care nephrology. These are all unquestionably impressive achievements, but, admittedly, do not tell readers of this Journal why we are enthusiastically recommending his book on American Heath Care Economics, entitled “Code Green How the Big Lie in Healthcare Affects Us All.” Therefore, just like Dr. Kellum, let us be candid.
This 190-page book is concise, cogent, and well-referenced, but it is also darn brave. Afterall, Kellum offer a no-holes barred critique of the 5 trillion-dollar United States healthcare industry. Again though, why should UK doctors care? Firstly, what happens in the “excited States of America” influences us all (trust us, we’re Canadian, we know). Next, this book was prescient given the recent apparent assassination of the United Healthcare CEO, Brian Thompson. As a reminder, the spent gun cartridges read “delay” “deny” and “defend”: terms associated with refusal of healthcare coverage. Regardless, if we really are, are we repeatedly claim, “patient focused,” then we should care about apparent injustice or systems where users appear to be pay more but receive less. We should also care if we believe practitioners are muzzled, and have responsibility but little power.
Kellum focuses on hospitals holding back care rather than insurers, but nonetheless points out inconvenient truths that may beggar belief. For example, hospitals are posting record profits and opening luxurious clinics around the world, all while claiming poverty and hoovering up tax breaks. Similarly, health care administrators are receiving millions in salaries not solely for care delivery, but for keeping staff in-check and advancing their brand. US Doctors (while admittedly also well paid) are also vulnerable employees with 1-year salaries. They serve at the pleasure of the CEO rather than patients, and woe betide the frontliner who is seen to “advocate too loudly.”
Kellum offers many cautionary tales relevant to anyone contemplating alternate healthcare models, wondering about relocating, or daring to blow the whistle. He also argues how the US healthcare was previously at fault for driving up costs by over-ordering (i.e. drugs, tests, or procedures), but has now added an additional venal sin: “shortchanging” patients by collecting fees while denying comprehensive care. Previously, US doctors could advocate because they dictated where patients would be admitted (and money follows admission). According to Kellum they are now effectively silenced, and beholden to the hospitals bean-counters.
Kellum outlines the dangers of monopolies – namely where there is only one seller – but also the dangers of monopsonies – namely where there is only one buyer. The point is that, fall out with your employer and you may be unable to work anywhere in that jurisdiction. Moreover, if you rack up massive student debts – as an increasing number of students will on both sides of the Atlantic – then you are less likely to speak truth to power. This is informative to anyone wanting to advocate: which should be all of us. Kellum also points out that feeling inauthentic or silenced can be a major contributor to burnout and can lead to widespread resignation (both literal and figurative).
No book is perfect, and this could so easily have been Americo-centric or one person’s opinion: fortunately, it is neither. Firstly, Kellum discusses systems from around the world and freely admits that US healthcare is often no better, and usually worse value for money. He avoids gratuitous emotion by grounding readers with objective comparative statistics. In fact, he even breathes life (excuse the ICU pun) into potentially staid topics such as Quality-Adjusted-Life-Years and Numbers-Needed-to-Treat. He also credits the good and great who have come before. In so doing he offers a primer on the broader topic of health care economics. Those luminaries include Dr. Don Berwick of the Institute of Healthcare Improvement and Dr. Marty Makary who wrote the influential book “The Price we Pay – what broke American healthcare, and how to fix it.” Kellum even includes Dr. Seuss and his apposite quote: “Unless someone like you cares a whole awful lot nothing is going to get better it’s not.” Well said Dr. Suess; well written Dr. Kellum.
