The NEXT “Big Short”: American Health Care


Leonard Zwelling

         It is great when Hollywood takes one of your favorite books
and makes it into a great movie. It happens so rarely. Coma, Rosemary’s Baby, Sophie’s Choice, The Godfather, Moneyball,
Silence of the Lambs
, and a few others come to mind. A very few others.

         When I heard that The
Big Short
by Michael Lewis was to be a motion picture, I was very
skeptical. The Big Short is a complex
but entertaining book, much like Moneyball
also written by Lewis, about an arcane subject, the mortgage market, and how
fraud and deceit and groupthink brought the entire American economy to its
knees because that market was so Byzantine it hid its innate flaws from all but
a few. But it is mostly the story about those few very smart men who saw it
coming and bet against the mortgage market or “sold it short.” They even had to
get the big banks to invent investment instruments to “make the market” for
mortgage-backed securities that they could bet would collapse. And it did.

men were in finance and believed that the market on which the mortgage-backed
securities invented by Wall Street was built was a House of Cards, a hedge in
front of a white picket fence that hid this ghastly structure with no foundation and
even less value. There were real alligators in the real swimming pools but you
couldn’t see that from Wall Street. You had to get down to Florida to see
clearly and even clearer from Las Vegas.

         The rest of Wall Street believed the mortgage market was
unsinkable. In fact, they invented ways to hide the worthlessness of the
product they were peddling so the market appeared robust. Then they built on
that and on that until the entire structure was so complex that no one
understood it. Until these guys.

         I will not ruin the film or the book by revealing any
particulars. I just wish to comment that I believe American health care today
is where the mortgage market was in 2003, about 5 years away from collapse.

         Simple. The underlying value of the product is awful and it costs too much.

the halls of the great academic centers like those in the TMC to the smaller
clinics throughout the great cities of America, the three parameters of
importance, access, cost and quality, are going to hell fueled by ObamaCare.

         Good luck getting to see a doctor when you need one (above
link from NY Times, Dec. 26) given
that their population is aging and their corporatization is now complete. You
better have great health insurance and it had better be underwritten by a
company whose card is in your wallet and who does business with your doctor’s
practice (unlikely your doctor him- or herself as he or she sold out to a practice
management conglomerate years ago).

         Be certain that the first test you will receive at any
hospital or practice is a wallet biopsy to make sure there is sufficient green
or insurance to defray the outrageous costs you are likely to incur on
unnecessary testing, imaging and referrals. Clinical judgment is a thing of the
past. Doctors get sued for using it and an MRI is so much faster.

         As for quality, what is it anyway?

         For some it is whether or not the latest issue of People Magazine is in the waiting room
or whether Dr. Smith (or his tie, if he is wearing one) is “nice.” For others
it is whether or not there is valet parking. And have you been to a high-end
plastic surgeon’s office recently? It looks like the Cantoni showroom. Someone has
to float the bill for that over-stuffed stuff and it won’t be the doc.

I offer you a water?”

course much of this goes toward the chasing of better “patient satisfaction”
evaluations. How many patients know anything about the care they are receiving?
Few. Remember, I diagnosed my own coronary disease and recent pulmonary embolus
and I had truly superior doctors. I trained with some of them and know them
all. These are the best in the city by reputation and judgment. No one is
perfect, especially us human doctors.

me quality is all about outcomes and how many doctors do you know who will tell
you what their batting average is? Few.

I got my heart by-passed at St. Luke’s, my idea of quality was the ability to
walk out of there a week later. Hell, yes I was satisfied and I was again 6
weeks ago when I walked out of St. Luke’s following major surgery having done
far less well previously at Hermann for a similar procedure.

like the mortgage market, the health care industrial complex has become an
apparent money making machine whose value is unknown to anyone, especially
those like Mr. Obama selling a market-based solution and then being surprised that
the prices rise and the price of life-saving therapy (new, anti-cancer drugs),
like that of affording a home in 2005, has started to escape the reach of the middle

I save my Countrywide award for sleight-of-hand for MD Anderson. I still cannot
understand how you hire more and more people, build more and more buildings,
and try to see more and more patients and still give the “best” in cancer care.
This is against every rule in medicine, organization management, and economics.
I don’t want to know the big number (total billings). I want to know what is
likely a far smaller one: how much does MD Anderson make on the next patient it
sees, and how much does hiring the next surgeon actually cost in a fully
allocated model, which I doubt anyone has?

wonder how many people who MD Anderson could help are turned away because they
cannot pass the green screen?

wonder how many patients do not get what their oncologist thinks is best simply
because the insurer will not cover it, the FDA will not sanction it, or the
patient’s family cannot afford it?

if I was going to judge the quality of medical care, I might start with a
source other than US News and World
. Heck, why not see how many stars MD Anderson gets on Yelp or
Amazon? There must be an app for that!

the next hit reality TV show will be a real-life version of the Firesign
Theater’s Beat the Reaper in which doctors will compete at diagnosing a real
person’s illness and giving them curative treatment on time.

believe the American health care market and MD Anderson, in particular, are due
for a major “correction.” The sooner the better.

I can say is that I am glad I got out and did so by getting fired because I
protested that the quality of care I was overseeing was inadequate. Silly me
for mistaking my supervisor for someone who might actually care.

Leonard Zwelling