What’s Wrong with Medicine Today: My Perspective After Forty Years in the System
An Honest Look in the Mirror | Part Nine
OPINION PIECE
This series has examined every major participant in the American healthcare system. Each has been held accountable in proportion to their contribution to what American healthcare has become. One participant has not been examined yet: the patient.
Intellectual honesty and scientific rigor demands we take a look to every player on the system, and that includes the patients. Before you turn the anger against me, I ask you to evaluate the arguments and evidence presented herein with an open mind and be willing to accept we, as the users of the system, share some portion of the responsibility as well.
The Copay Is Not the Price
Employer-sponsored insurance covered approximately 159 million Americans in 2023. The average employer contribution to family coverage was $16,357 annually or roughly 73% of the total premium (KFF Employer Health Benefits Survey, 2023). Medicare and Medicaid together covered approximately 140 million Americans at a combined federal and state expenditure exceeding $1.5 trillion annually (CMS National Health Expenditure Data, 2023).
The person who believes the copay is their entire financial participation in the healthcare transaction is mistaken. They are paying for everyone else’s avoidable consumption, and everyone else is paying for theirs in return.
When Patients Ask For That They Do Not Need
Approximately 30% of all outpatient antibiotic prescriptions, 47 million annually, are unnecessary, written primarily for viral respiratory ailments (Fleming-Dutra KE et al., JAMA, 2016). Sinusitis is the single diagnosis generating the most antibiotic prescriptions in American outpatient medicine: 56 per 1,000 population annually. Inappropriate prescribing for sinusitis and pharyngitis alone cost the privately insured system $69 million in excess spending in a single study year (Pew Charitable Trusts, 2023). The ultimate consequence is 2 million antibiotic-resistant infections and 23,000 deaths annually at a system cost of $30 billion (CDC, Antibiotic Resistance Threats, 2019).
Direct-to-consumer pharmaceutical advertising influences patient behavior as well. It encourage patients on stable treatment to ask (in some cases demand) a switch to a newer, heavily marketed equivalent with no demonstrated clinical superiority. The cost difference falls on the insurer and ultimately on all premium payers.
Physician shopping, seeking additional opinions until the desired outcome is obtained, compounds both problems. It circumvents the clinical judgment the system depends on, generates costs at every consultation, and creates a documented market incentive for the physician willing to provide the desired answer. This does not apply to patients rightfully seeking second opinions for serious or unexpected conditions, those are legitimate and most competent physicians will encourage them.
The professional consequence for the physician who fails to comply is swift. The patient leaves, posts a negative review, and usually transfers care to a physician who will comply. This ends penalizing the original physician’s clinical integrity, while financially incentivizing unprofessional behavior.
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Brand Name Over Generic
Generic drugs are required by the FDA to be bioequivalent to their brand name counterparts: identical in active ingredient, dosage form, route of administration, strength, and therapeutic effect. A review of bioequivalence data from more than 2,000 FDA-approved clinical pharmacokinetic trials found no significant difference in therapeutic effect between branded and generic drugs (Califf RM et al., PMC5417581). Generics cost approximately 80 to 85% less than their brand name equivalents. Between 2009 and 2019, generic drug use saved the US healthcare system nearly $2 trillion (FDA, Generic Drugs: Questions and Answers).
Despite this, more than one-third of patients report a preference for branded products over generics, and 46% have asked their physician to prescribe a brand name drug over an available generic alternative (Shrank WH et al., PMC1852907). Patient requests for brand name drugs over generically equivalent alternatives cost the Medicare Part D program $673 million in 2017 alone, and cost Medicare patients themselves an additional $109 million in unnecessary out-of-pocket spending in the same year (Bai G et al., JAMA Network Open, 2021). Across the entire healthcare system, unnecessary brand name dispensing when generic equivalents are available generates an estimated $8.8 billion in excess expenditure annually.
The Motorized Scooter Bubble
Medicare covers power wheelchairs and motorized scooters as durable medical equipment for beneficiaries with documented severe mobility impairment who cannot operate a manual wheelchair. The Scooter Store, the largest power wheelchair supplier with approximately 80% of its revenue derived from Medicare patients, launched a television campaign in late 1990s and 2000s telling elderly viewers they needed a power scooter to live an independent life, they were entitled to one, and Medicare would pay for it. This campaign created a growing demand from medicare beneficiaries seeking their own motorized scooter benefits from physicians oftentimes without identifiable medical need.
Physician who found no qualifying mobility impairment were positioned by the company as the obstacle, fostering an adversarial relationship between patient and physician. Former Scooter Store employees testified that the company ranked physicians by their willingness to prescribe and operated programs specifically designed to pressure physicians who had declined to certify patients as qualifying (DePaul Journal of Health Care Law; Washington Post, August 2014).
The Department of Health and Human Services Inspector General found that 80% of Medicare payments for power wheelchairs industry-wide were made in error, the majority to people who did not need the equipment or lacked documentation of need (HHS OIG Report OEI-03-02-00600, 2004). Since 1999, Medicare made more than $8 billion in payments for 2.7 million wheelchairs and scooters. The prescription rate for power wheelchairs increased 33-fold between 1994 and 2001 — a trajectory tracking precisely with the expansion of direct-to-consumer durable medical equipment advertising during the same period (Kessler D et al., PMC1850931). The government was aware of the fraud pattern as early as 1998 and did not act substantively until 2003 to 2004.
When Patients Stop Treatment
Medication non-adherence costs the US healthcare system between $100 billion and $300 billion annually in avoidable spending (Iuga AO, McGuire MJ, Risk Management and Healthcare Policy, 2014; Cutler RL et al., BMJ Open, 2018). It is associated with 125,000 preventable deaths annually and accounts for up to 25% of hospitalizations (Bosworth HB et al., Duke Health, 2018).
A portion of non-adherence episodes are attributable to populations at significant socioeconomic disadvantage making it often impossible to maintain medical compliance. While they do contribute to the figures cited above, their lack of medical compliance is certainly non-malicious. A different group of patients are willfully non-compliant, seeking care and stopping it for no excusable reasons. In my experience the latter group is significantly smaller, but no official numbers to distinguish these populations are available for review.
The well defined consequences from patient non-adherence are quality penalties and negative readmission metrics that fall on physicians and institutions alike. The Hospital Readmissions Reduction Program penalizes hospitals for readmissions without adjustment for whether the patient discharged against medical advice, stopped their medications the day after discharge, or returned directly to the lifestyle that produced the original admission.
What Patients Do Not Change
Chronic diseases consume approximately 90% of the nation’s $4.9 trillion annual healthcare spending (CDC, Fast Facts, 2025). The majority are significantly preventable or modifiable through behavioral change.
The specific cost figures:
Smoking-related disease exceeds $240 billion.
Obesity costs the healthcare system approximately $173 billion annually (Biener A et al., Health Affairs, 2010).
Physical inactivity costs $192 billion (NHLBI, 2019).
Poor diet accounts for approximately $50 billion in cardiometabolic disease costs (Pearson-Stuttard J et al., PLOS Medicine, 2019).
I acknowledge behavioral change is difficult, and socioeconomic conditions make it more difficult for some more than others. However it does not change what the behaviors cost society at large.
The physician who has repeated the goals-of-care conversation, adjusted medications to accommodate behaviors that do not change, ordered tests required by progressive deterioration, often find the patient and family attribute the lack of improvement to inadequate medical care instead.
What Families Do
End-of-life care (depending on how end-of-life is defined) consumes approximately 25% of all Medicare spending (Riley GF, Lubitz JD, Health Services Research, 2010; Aldridge MD, Kelley AS, American Journal of Public Health, 2015). The median Medicare expenditure in the last six months of life exceeds $28,000 per beneficiary. This is exacerbated by families that, purely out of grief, request every available life-sustaining intervention for patients with terminal diagnoses and no realistic prognosis for recovery. While I don’t condemn their motivations, their actions do contribute to the increasing financial stress of our healthcare system.
On the other hand, I have directly experienced families that actively undermine inpatient care by delivering contraband; the most common being food and cigarettes, although in rare instances, it can also include alcohol and even street drugs. Whether this stems from misguided love or loyalty, this behavior directly prevents the clinical outcomes the care team is being held accountable for producing, often leading to prolonged hospital stays with the increased costs and penalties already discussed elsewhere.
What Patients Do Not Disclose
Dietary supplements generate approximately 23,000 emergency department visits and 2,000 hospitalizations annually in the United States, based on nationally representative surveillance data from 63 emergency departments collected between 2004 and 2013 (Geller AI et al., NEJM, 2015). Disclosure rates for supplement use to treating physicians are estimated at 25 to 33% (Awortwe C et al., Frontiers in Pharmacology, 2025).
The problem here is not the patient decision to use a supplement, is the undisclosed supplement use along with prescription medications.
A patient on warfarin or a direct oral anticoagulant using a supplement with known antiplatelet or anticoagulant properties — Ginkgo biloba, fish oil at high doses, vitamin E, nattokinase — without disclosing it, is unknowingly creating a bleeding risk. The resulting hemorrhagic event requires hospital care for management of both the bleeding and associated complications. That episode was preventable by a single conversation that did not happen.
The Honest Close
This series demands addressing the public conversation society avoids. Patients are participants in the system, and participation carries rights and responsibilities.
Our healthcare system has an obligation to every patient regardless of the choices they make. That obligation is not conditional on behavior and it should not be. Healthcare resources are finite, that is an unavoidable fact. If we want the resources to meet the needs of society we need to hold all parties equally accountable for the efficient allocations of such resources.
One of those parties, is the patient.
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I am not a physician, rather was a Clinical Assistant to several psysicians throughout my four decades of being a part of the health care profession.
I agree with the majority of your article. However, I would like to make note of a couple of things that were not mentioned when speaking of Branded medications.
My experience, working in the medical field prove two very notable things. First and foremost, all generics are NOT EQUAL as the “fillers” used vary from Brand as well as among companies. I personally witnessed the decline of the majority of our decades long stable patient population when two of our daily medications went generic. Both of these medications took months and in some patients, years, to reach therapeutic dose. As I said they were established stable patients. Both medications required slow titration to discontinue. One of the medications required increased dose to achieve the therapeutic effect of Brand. This is CLINICAL WITNESSED FACT. The decline did not occur overnight, rather, 3-6mos before we recognized the pattern. All had been switch to generic.
The second, and I feel unbelievably egregious, is that while all of our hard working paying patients were forced onto generic medications; our patients on MEDICAID were allowed FIVE(5) Brand medications, paid for with those patients, and all working class persons tax dollars.
I have been out of the medical field for almost a decade & can only hope that there have been positive changes but admittedly doubt much has.
Are you both saying Medicaid patients don’t deserve brand name care? Or that it should be equitable with Medicare? Hopefully the latter.