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January 30, 2023

Salve Lucrum: The Existential Threat of Greed in US Health Care

Author Affiliations
  • 1Institute for Healthcare Improvement, Boston, Massachusetts
JAMA. 2023;329(8):629-630. doi:10.1001/jama.2023.0846

In the mosaic floor of the opulent atrium of a house excavated at Pompeii is a slogan ironic for being buried under 16 feet of volcanic ash: Salve Lucrum, it reads, “Hail, Profit.” That mosaic would be a fitting decoration today in many of health care’s atria.

The grip of financial self-interest in US health care is becoming a stranglehold, with dangerous and pervasive consequences. No sector of US health care is immune from the immoderate pursuit of profit, neither drug companies, nor insurers, nor hospitals, nor investors, nor physician practices.

Rapidly increasing pharmaceutical costs are now familiar to the public. Pharmaceutical companies have used monopoly ownership of medications to raise prices to stratospheric levels, and not just for new drugs. Flaws in US patent laws leave loopholes allowing profiteering drug companies to gain control of some simple and long-known medications and to raise prices without constraint. Eye-popping prices for new, essential biological and biosimilar drugs, enabled by the failure of any serious drug price regulation, have yielded enormous profits for drug companies even though much of the basic biological research funding has come from governmental sources.

Particularly costly has been profiteering among insurance companies participating in the Medicare Advantage (MA) program. Originally intended to give Medicare beneficiaries the choice of access to well-managed care at lower cost, MA has mushroomed into a massive program, now about to cover more than 50% of all Medicare beneficiaries and costing far more per beneficiary than traditional Medicare ever has.1 By gaming Medicare risk codes and the ways in which comparative “benchmarks” are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies. According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare.2 Opinions differ about whether MA enrollees experience better care and outcomes than those in traditional Medicare, but the weight of evidence is that they do not.

Hospital pricing games are also widespread. Hospitals claim large operating losses, especially in the COVID pandemic period, but large systems sit on balance sheets with tens of billions of dollars in the bank or invested. Hospital prices for the top 37 infused cancer drugs averaged 86.2% higher per unit than in physician offices.3 A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose.4 To drive up their own revenues, many hospitals serving wealthy populations take advantage of a federal subsidy program originally intended to reduce drug costs for people with low income.5

Recent New York Times investigations have reported on nonprofit hospitals’ reducing and closing services in poor areas while opening new ones in wealthy suburbs and on their use of collection agencies for pursuing payment from patients with low income.6 The Massachusetts Health Policy Commission reported in 2022 that hospital prices and revenues increased during a decade at almost 4 times the rate of inflation.7

Windfall profits also appear in salaries and benefits for many health care executives. Of the 10 highest paid among all corporate executives in the US in 2020, 3 were from Oak Street Health, and salary and benefits included, reportedly, $568 million for the chief executive officer (CEO). Executives in large hospital systems commonly have salaries and benefits of several million dollars a year.8 Some academic medical centers’ boards allow their CEO to serve for 6-figure stipends and multimillion-dollar stock options on outside company boards, including ones that supply products and services to the medical center.

Avarice is manifest in mergers leading to market concentration, which, despite pleas of “economies of scale,” almost always raise costs. That is what is happening as hospital consolidations proceed largely unchecked in many urban markets9 and as physician practices are purchased by for-profit firms. Mergers, acquisitions, and public offerings have been occurring throughout health care, often at valuations that defy logic. Oak Street Health, an innovative primary care company that employs physicians and plays heavily in MA, had a $15 billion initial public offering in 2022, equivalent to $196 000 per patient in their panel.

Profit may have its place in motivating innovation and higher quality in health care, as in any industry. But kleptocapitalist behaviors that raise prices, salaries, market power, and government payment to extreme levels hurt patients and families, vulnerable institutions, governmental programs, small and large businesses, and workforce morale. Those behaviors, mostly legal but nonetheless wrong, have now accumulated to a level that poses an existential threat to a sustainable, equitable, and compassionate health care system.

For individuals, the costs can be extremely painful.

A total of 41% of US adults, 100 million people, bear medical debts. One of every 8 individuals owes more than $10 000. In Massachusetts, 46% of adults say they skip needed care because of costs. As of 2021, 58% of all debt collections in the US are for medical bills.10 Health insurance premiums in Massachusetts have gone up more than 200% in 2 decades and now cost more annually per family than a car. People of lower income must choose high-deductible plans; they cannot afford more complete coverage. In no other developed nation on earth is deep medical debt as present a threat as in the US.

Greed harms the cultures of compassion and professionalism that are bedrock to healing care. Health care executives and board members who know better nonetheless feel compelled to play the games of pricing, acquisition, and revenue maximization that others do. Professionals find themselves trapped in record keeping, coding behaviors, and productivity imperatives that belie the reasons many went into health care in the first place. “Moral injury” is the harvest, with demoralization and disengagement to follow.

US health care costs nearly twice as much as care in any other developed nation, whereas US health status, equity, and longevity lag far behind. Unchecked greed is not the only driver of that failure, but it is a major one. Few, if any, other developed nations tolerate the levels of avarice, manipulation, and profiteering in health care that the US does. Salve lucrum is the wrong answer.

What to do about greed? No answer is easy, not least because of the political lobbying might of individuals and organizations that are thriving under the current laxity. The cycle is vicious: unchecked greed concentrates wealth, wealth concentrates political power, and political power blocks constraints on greed.

Perhaps the demoralization of professionals, the conflicted consciences of many executives, and the anger of the public represent potential political energy that, with proper leadership, can become kinetic.

First, health care professionals in all disciplines need to become noisier about the conflict between unchecked greed and the duty to heal. Extortionate drug prices, exploitation of market consolidation, coding games, excessive executive compensation, and promulgation of unnecessary care ought not to be met with silence. Silence is assent.

Second, health care professionals should insist that their guilds and trade organizations demote the pursuit of higher payment among their priorities. They should insist that resources flow to the neediest in our society. The protection of patients—all patients—is the first and highest calling, and that includes protection against onerous medical debt and bankruptcy.

Third, health care leaders and professionals should lobby Congress to pass legislation to rein in greed. Reforming patent laws, changing coding and billing rules, strengthening antitrust enforcement, expanding price transparency, and accelerating global budgets for the care of populations are agendas that have languished without strong action in Congress for years because the money of incumbents drowns out the greater public interest.

Fourth, health care professionals should insist that their organizations invest actively in improving the true social influences on health. America’s hospitals should bring a fair share of their resources to mitigating the actual causes of illness, injury, and disability.

The glorification of profit, salve lucrum, is harming both care and health. Health care should not be an engine for excessive private gain.

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Article Information

Corresponding Author: Donald M. Berwick, MD, MPP, 131 Lake Ave, Newton, MA 02459 (donberwick@gmail.com).

Published Online: January 30, 2023. doi:10.1001/jama.2023.0846

Conflict of Interest Disclosures: None reported.

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34 Comments for this article
Our Calling Is To Make It Better
Gerald Early, M.D., M.A. | IQVIA

Dr. Berwick has successfully avoided moral grandstanding while reaching out to us to advocate for the high road.

Our healthcare system is less than it should be and could be, and reflects on me as something less than what I aspire to be.

Kudos on your editorial
Bill Vasak, BS Pharmacy | Private practice
Excellent commentary! You mirror my thoughts precisely!
Thank you!
This Essay Deserves Wider Publication
Darryl Anderson, MBA, JD | Attorney
This is the most succinct and effective description I have seen of the problem we have with health care costs. It deserves wider publication. I particularly appreciate the fact that the author uses data to make his point and that he provides sources for the data he uses.
CONFLICT OF INTEREST: One of my clients is a health insurance company.
Hail Profit
Anthony Perry, MD | Retired general internist
The profit motive stimulates optimum productivity and maximizes value for purchasers. Central control leads to mediocrity, waste and favoritism, and, yes, personal interest will prevail in the operations of whoever does the controlling.

Excessive prices and waste in medical goods and services in the U.S. is due to unnecessary government intervention and third-party involvement in payment. These things are controlled to some extent elsewhere by rationing.

Greed will never be removed from human interactions. What keeps it in check is free competition.

JAMA should publish an editorial which presents an opposite viewpoint.
Define Greed
Michael Gross, M.D. | University of Michigan
Greed and avarice are bad qualities. The Bible tells us so. How do I know when I am greedy? My salary? My mortgage? My car? Sure, a CEO with a $50 million paycheck sounds avaricious to me. And to see that money come out of undelivered services makes me sick. And some seven-figure CEO has me spending my time begging someone to authorize a generic that's not on his formulary. But to poke this bear in the eye, we may stir up income control on "providers," you know, "doctors." What about my orthopedic surgeon? Well, he accepts my Medicare, so let him off the hook for his annual gross. I'm a psychiatrist. Pity me and the pediatricians. It gets complicated unless you impose a pre-ordained income on everyone, providers and administrators and their corporations. And what do we have at that point? In some parts of Canada, the next MRI machine can be 200 miles down the road. That said, when a patient can't afford an epi-pen, something stinks. When hospitals close in minority neighborhoods, we have a problem. When a person in this country has to decide whether to pay the rent or get his medicine, where are we?
The Only Real Solution is Medicare for All
George Bohmfalk, MD | Neurosurgery, retired
Dr. Berwick listed four suggestions to address the obvious problems of greed and profit in healthcare, but it's unlikely any would change much except for lobbying Congress to pass Improved Medicare for All. If every one of the 55-60% of US physicians who profess to support a universal system of publicly-funded and privately-delivered healthcare would join Physicians for a National Health Program, such lobbying might actually succeed.
CONFLICT OF INTEREST: Chair, Health Care Justice North Carolina, chapter of PHNP
Stand Up Triple
Keith Loud, MDCM, MSc | Geisel School of Medicine at Dartmouth
As a huge fan of Dr. Berwick's Viewpoints, I was excited to see this. As usual, it lays out the challenges and failings of US health care with great clarity, identifying the culpable parties.

But rather than his usual home run, I'd call this a stand-up triple. Calling on health care professionals - physicians in particular - to work against their financial self-interest seems surprisingly naive.

As the late economist Uwe Reinhardt may have said, "it is the prices stupid." Unchecked by the "hidden hand" of a true free market, health care can command exorbitant prices to
serve the profit motive. Indeed it is us physicians (and other health care professionals) who actually comprise the market, purchasing the labs, imaging, and other tests and procedures on behalf of our patients, along with prescribing drugs for them. We have expensive tastes, especially when spending other people's money.

Moreover, we are increasingly employed by hospitals and health systems, and therefore have a vested interest in the (profit) margins that those systems can generate. Our hands fit neatly into the velvet gloves, especially as health care CEOs increasingly have an MD or DO after their names.

We health care professionals should rail against unchecked greed in the pharmaceutical and insurance industries; lobby Congress to pass laws to control spiraling costs; advocate for investment in the true drivers of health (although that would need to come at the expense of Medicaid and Medicare spending that funds health care); and "insist that their guilds and trade organizations demote the pursuit of higher payment among their priorities."

The latter two invoke "Medice, cura te ipsum" (Physician, heal thyself), which could allow us to free ourselves from the yoke of documenting in the EMR, which is fundamentally a coding and billing tool. Alas, I fear it is the payers - employers and the public - that will need to knock us from the proverbial top 1% of compensation (probably no further than the top 2%) for our own good.

One Point Missing
Sally Benford | Patient
The essay does not mention primary care physicians who have changed their practices to a concierge medicine model and have abandoned patients who can't afford or don't want to pay exorbitant annual fees just to have access to their physician. Those physicians are still billing insurance companies and Medicare.
Especially Among Older Adults
Mario Garrett, PhD, Professor | San Diego State University
The zeal for profit in the healthcare industry is especially obvious in older adult healthcare. The process of the continuum of care feels very much like a butchering, each step calculated to extract as much money as possible (mostly from insurance, Medicare, and Medicaid).
CONFLICT OF INTEREST: Author, Critical Age Theory
A Slap in the Face to Primary Care Doctors
Nicholas Tito, DO | Private Practice, Psychiatry
Physician groups shouldn't advocate for higher (fair) reimbursement? NHS physicians are on strike in March because they make pennies and work more hours. The primary care doctor is the workhorse of the healthcare system and they already see reimbursement rates that are laughable. This piece is utopian well-wishing, nothing more.
The System Is Structured Like a Malignant Tumor
Dave deBronkart | "e-Patient Dave" Business
Thank you for naming the nature of the beast.

The structural issue is that the US health system is a galaxy of individual organizations, each with its own financial needs (even if they're not greedy), and no one is accountable if money flows but care never happens. I've come to understand that the structure of this system produces these results even if there are no evil people in the top jobs.

As a survivor of a near-fatal cancer, I'm grateful for what medical science and great clinicians continue to achieve. But I'm also
keenly aware of the extreme stress too often inflicted on the doctors and nurses who care for me, countless hours of unpaid time coping with bureaucrats whose unspoken principle is "No, sorry, we need the money, so you can't do what you want." Perversely, the people who say "We're not paying" are commonly called "payors" even when they don't pay. And that reflects, again, the cash-centric view that's become the default. They're insurers, not "payors."

What to do? Before cancer, in industry I learned to take an analytical approach to wicked problems. After speaking at hundreds of medical events in dozens of countries, I found my answer, and blogged it:

"American healthcare is a malignant tumor that can’t stop killing its host":

- Like a tumor, it wants to grow, and is good at it.
- To do this, it draws nutrients (cash) from other organs, even if it suffocates them
- It may crush other living things that get in its way.
- The needs of the tumor (financial system) outweigh, and may kill ("existential threat") the host.

It's not just patients and clinicians who are getting crushed; I'm even starting to hear of good-hearted hospital executives who've given up.

It's time to recognize that all these system behaviors will persist until the design of the system is broken up.

(Additional information: Conflict of interest disclosure)

CONFLICT OF INTEREST: Book royalties, speaker's fees, other
American College of Physicians's Position on Financial Profit in Medicine
Omar Atiq, MBBS (MD) | President Elect, American College of Physicians; Professor, University of Arkansas for Medical Sciences
We concur with Dr. Berwick that the pursuit of profit in health care threatens to overshadow the centrality of the patient-physician relationship and the broader goals of the Triple Aim: improving population health, enhancing the care experience, and reducing costs. (Stakeholders have rightly called for the Triple Aim to be expanded to include achieving workforce well-being and advancing health equity.)

The American College of Physicians (ACP) in their 2021 position paper Financial Profit in Medicine raised concern that the unchecked profit motive in medicine and the broader health care system is undermining the patient-physician relationship and diminishing trust in the
profession (1-3). Examples abound, including the rising interest of private equity in medicine, non-profit hospitals losing sense of their community-oriented mission, and higher prices and premiums from consolidation and integration of health care and payers.

The profit drive may appease shareholders, but does it benefit our patients? Dr. Berwick makes a compelling case that it does not and the U.S. health care system continues to have higher costs, poorer access to care, and lower quality compared to other high-income countries. We recommend more insight and oversight of private equity and corporate entities in medicine to better understand the impact on our patients, the health of our communities, and the quality of care delivered.

Dr. Berwick calls on health care professional organizations to “demote the pursuit of higher payment among their priorities” and ramp up their advocacy efforts to ensure resources flow to the neediest in society. We believe that physicians are “permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical ethics.” Physicians should be able to earn a living and keep their practices open, but the sanctity of the patient-physician relationship and their professional obligations to the community must not be compromised.

To cultivate trust among patients, physicians, and the broader community, ACP also calls for policymakers to achieve universal, comprehensive coverage; payment and delivery system reforms that promote primary care; more transparency of cost, ownership, and quality information; and reasonable policies to regulate excessive health care and prescription drug prices, including all-payer rate setting and global budgets. Physicians and other health care professionals should eliminate, or at least be transparent about, any potential financial conflicts of interest.

The health care system must do more to address socioeconomic inequalities that have a negative impact on health, such as food insecurity. To fulfill their community benefit obligations, non-profit hospitals should explore ways to address social drivers of health in their community. Other hospitals and health systems should follow suit. Physician payment models can be reformed to better address value and achieve health equity.


1. Crowley R, Atiq O, Hilden D; Health and Public Policy Committee of the American College of Physicians. Financial Profit in Medicine: A Position Paper From the American College of Physicians. Ann Intern Med. 2021 Oct;174(10):1447-1449. doi: 10.7326/M21-1178. Epub 2021 Sep 7. PMID: 34487452 https://www.acpjournals.org/doi/10.7326/m21-117

2. Lo B, Grady D. Financial Profit: Not the Mission of Medicine. Ann Intern Med. 2021 Oct;174(10):1466-1467. doi: 10.7326/M21-3220. Epub 2021 Sep 7. PMID: 34487453

3. Healio Q&A: ACP calls on health systems to prioritize patients over profit. https://www.healio.com/news/primary-care/20210908/qa-acp-calls-on-health-systems-to-prioritize-patients-over-profit. Accessed 2/1/2023

CONFLICT OF INTEREST: PI on Pharma sponsored trials at UAMS in past; Stock ownership in Texas Regional Medical Center; Mutual funds and ETFs in Retirement accounts may own healthcare related stocks
Medicare Abuse in Tube Feeding
John James, Retired | Patient
I received an unexpected $1500+ bill for tube feeding supplies, mostly for liquid food. I had expected a smaller co-pay, so asked my insurance company why they didn't cover this necessary expense that was prescribed by my doctor. They said they did cover it, and "paid" thousands of dollars (they told me the exact amount for one item), though it actually was just passed through by the government, paid for by my Medicare Advantage program, not the insurance company.

It turned out that a small company (which my doctor directed me to use) charged about five times the market
price charged by Amazon, or by the manufacturer, Nestle, for exactly the same product. Medicare paid 80% of that and I paid 20%, essentially the market price. All three sources delivered the product for no extra charge.

The result is that the Medicare benefit to the patient is nullified, and the government pays 4 times what the patient pays, for nothing at all. The confusing billing obscures this situation.
Rating System
Monte Moore, MD | Retired
Dr. Berwick has raised a courageous and much needed voice. It’s true that unbridled greed demoralizes us, America’s health care providers, as well as those who should be able to look to us as healers. Healing goes far beyond having the correct medical answer.

Desire for profit can be a good thing if balanced by the stronger imperative to improve the lives of those we serve.

I urge each of us and our organizations to raise awareness of and promote Dr. Berwick’s recommendations.

Monte H Moore, MD
Even Health Science Schools
Roger Galburt, DDS, Professor Emeritus | Tufts University School of Dental Medicine
Private dental education in Boston is now in the range of $100,000 a year and with room and board it is looking like half a million US dollars to become a dentist. This has to affect costs as this money has to be returned to loan sources. Educational institutions constantly use excess revenue to construct new buildings and lobbies instead of lowering tuition and increasing faculty.

Salve lucrum.
Perverse Incentives
Steven Reid, MD, FAANS | Doctor Lifeline, Incorporated
The shift from private practice to physician employment deprived doctors of a great deal of personal agency. It's simple to connect the dots to show perverse financial incentives for hospital and health care systems lead directly to learned helplessness, moral injury, and physician suicides.
Greed is Not the Problem
A Pinheiro, MD, PhD, MHA | ENT, Memorial Medical Center, Florida
How do you define greed in medicine or elsewhere? If I see someone who makes $10M trying to make another million, I may see it as greedy. But if I make $100k and try to make another $10k that may seem greedy to the person who makes $40k.

Being compensated for providing services is not greedy. The best way to keep prices and greed in check is to have a free market. What we have in healthcare is far removed from a free market. The consumers and the providers are insulated from the real costs. The actual cost is
inflated for this reason. Try prescribing a $500 medication to your self-pay patient. He or she will immediately ask you if there is a cheaper alternative or if that medicine is really necessary. If it is a lifesaving med and no one can afford it then the pharmaceutical company will make no profit. They will have to lower the price in order to sell it because without sales there is no profit. And if the pharmaceutical company is making a huge profit on that med, another will come along with a similar drug which will introduce competition and lower the profit of the first company.

The costs of healthcare have consistently risen at a pace much higher than inflation. Why is that? It's simply because we have introduced more and more interventions (many to control costs) that continue to insulate us all from the costs of healthcare services.

Physicians can not compete for employment because many (most) states allow restrictive covenants. We cannot offer reduced fee services as we see fit because we cannot charge lower rates than Medicare. What kept greed in check in the past? Was it better legislation? Or perhaps the lack of legislation governing healthcare?

The author wants more government intervention to control greed. I am sure that will work as well as all other pieces of legislation introduced to control cost.
Group Purchasing Organizations and Health Care Greed
Phillip Zweig, M.B.A. | Executive Director and Co-Founder, Physicians Against Drug Shortages Inc. (PADS)
I agree completely that greed drives US healthcare. However, Dr. Berwick omits from his list of medical profiteers an industry that exists only to enrich insiders: giant, for-profit middlemen called hospital group purchasing organizations (GPOs). The largest, Vizient, Premier Inc., and HealthTrustpg, control most of an estimated $300 billion in annual purchases of drugs, devices, supplies and services for thousands of hospitals, nursing homes, and other facilities.

When founded in 1910 at New York’s Bellevue Hospital, their sole purpose was to save member hospitals money by buying in bulk. Members paid dues to cover administrative costs, a co-op
model that worked well for 80+ years. But in 1987, at the behest of hospital lobbyists, Congress enacted the misbegotten Medicare anti-kickback "safe harbor" statute, which exempted them from criminal prosecution for taking kickbacks from suppliers. The goal was to "codify" existing practice. Implementation of the rules by the HHS Inspector General in 1991 gave rise to a vast pay-to-play scheme and higher, not lower, supply prices.

GPOs now make their money by selling market share in the form of sole-source contracts to the highest bidders. In turn, they often award "share backs" to CEOs of major shareholder facilities for enforcing compliance with their secret contracts. Besides blocking entrepreneurial medical device makers from marketing their innovative and often cheaper products to GPO-member facilities, they've caused chronic shortages of hundreds of generic drugs, mostly injectables like sterile saline, chemotherapy agents, sedatives, and antibiotics. With the onset of the pandemic, these abuses contributed mightily to the scarcity of N95 masks and other personal protection equipment (PPE). On April 30, 2002, after several media exposes on these predators, the Senate Antitrust Subcommittee held the first of four hearings on anticompetitive GPO practices. Led by Senators Herb Kohl (D-WI) and Mike DeWine (R-OH), the panel revealed egregious instances of self-dealing and conflicts of interest. In 2005, they drafted a bipartisan bill that would have repealed the unsafe safe harbor, but it was stillborn because of the fierce opposition of the GPO and hospital industries.

To maintain this system, GPOs and their cohorts have lobbied members of Congress and added media celebrities, academics, former senior federal officials, medical societies, and nonprofits to their payrolls. Two of the top sponsors of Dr. Berwick's Institute for Healthcare Improvement's annual conferences are Vizient and Premier. Its former CEO Richard Norling, who appeared before that first Antitrust hearing for a lambasting, was appointed an IHI senior fellow. Vizient was the focus of a 5/22/22 60 Minutes segment entitled "In Short Supply," which explained how huge GPO "fees" (aka kickbacks) had caused the chronic shortage of vincristine, essential for treating childhood cancers. On 8/17/17, I attended a talk on Martha's Vineyard by Dr. Berwick called "Healthcare as it should be." During the Q&A, I asked if I could make a comment. I then made my case, as above, on how these cartels had busted the healthcare supply chain. He replied, "I don't disagree with you."

Salve Corde et Lucrum?
Teng Liaw, MBBS, PhD, FRACGP | UNSW Sydney
A succinct and to-the-point commentary on this aspect of the spiraling decline of our society. Can our humanity surface from this morass of greed? Can we achieve a constructive and productive balance between "common prosperity" and "philanthropy"?
In Cuius Parte Veritas? On Whose Side Is Truth?
Jacob Korula, MD | Gastroenterology and Hepatology, Private Practice
On initial read this appears like a clarion call to action to address the healthcare crisis in this country. A deeper look however reveals that this Viewpoint is not new, is something we have known for at least two decades, a process that evolved brazenly to overt exploitation by corporate businesses in healthcare with quiet acquiescence from leaders and beneficiaries. Physicians and patients are the central points in healthcare, yet these two components are the least regarded in this process. Dr Berwick invokes physicians to be noisier and concludes that silence is assent to avarice in the system.

are several aspects of the assertions that suggest some disingenuity. 

The author's organization, the Institute of Healthcare Improvement (IHI), received a grant of 25 million dollars from the Blue Shield Insurance Company to further its mission. Was insurance company greed an issue at that time? While serving as Interim Administrator for Center for Medicare and Medicaid Services, did Dr. Berwick foresee potential misuse of Medicare Advantage program? (Curiously, Kaiser Permanente, considered the exemplar of the managed care organization model that benefits from the costly Medicare Advantage program, is at the forefront now to describe this issue.) His opinion that fee for service care leads to increased healthcare cost, wrongly casting managed care as the future in this country while expanding that program, isolated and marginalized fee for service care. Is it fair for the author to expound on the issue of existential greed in US healthcare when he may have benefited from it?

In addition, the author has lectured to physicians and healthcare providers on how to improve patient care and safety and promoted the prevention of medical errors, recommended by the Institute of Medicine as a commendable goal - the so-called 'Triple Aim' directed to patient safety and welfare. An emphasis on the Quadruple Aim which would add protection of physicians may have helped mitigate burnout that is prevalent today.

The conclusion that physician silence fosters the status quo ignores the tribulations that besiege practicing physicians who confront increasing bureaucratic hurdles every day that impede care and leaves little time for “noise.” As a patient advocate, I have written numerous letters questioning authorization for drugs and procedures, appealing to almost all indemnity insurance companies and managed care organizations, most of whom are aligned to shareholders, to CMS Medicare, MediCal, California Department of Managed Care and even to a Congressman that were hopelessly futile. On appealing to the failure of Medicare’s Promoting Interoperability designed to facilitate easier digital communication between physicians but causing hardship instead of better care, my letters to CMS and to a Senator were ignored and unheeded. Thus, individual noisiness in this system is ineffective but collective noise also lacks clout because physician office bearers of medical organizations have been notably docile in challenging the pillage of the system.

Revolutionary changes in US Healthcare are needed and I am tenuously optimistic that it will occur. Books like Dr Ezekiel Emmanuel's Healthcare Guaranteed, A Simple Secure Solution for America, have proven unhelpful. Change as outlined by this Viewpoint is not expected to occur from business-as-usual top-down directives but from astutely innovative proposals, perhaps from the physicians in the trenches.

Best Commentary
Michael O'Shaughnessy, Assoc. Clinical Professor | University of California San Francisco-Fresno
Dr. Berwick's essay is the "Gettysburg Address" of health care cost commentary.
Mark Mc Connell, M.D. | Private practice
Dr. Berwick's points are timely, convicting, and excellent.

However one additional element may be worth examination. Not only is health care too expensive, but my observation is that we are doing too much of it. If there were more critical, clinical, thinking we could reduce not only the over-testing, over-diagnosis, and over-treatment, but also reduce the "cascade" of test, consults, and medications that are generated from tests either not indicated or those of only marginal value. We must be good stewards of limited resources - especially since patients are not really consumers: we who write orders are. />
Salve Lucrum: The Existential Threat of Greed in US Health Care
Brian Birch, MD (Cantab) | University Hospital Southampton NHS FT
As a urologist working in the UK I was particularly struck by the finding that "a patient was billed $73,800 at the University of Chicago Medicine for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose." This is both ethically and morally indefensible and the hospital concerned should be asking themselves some serious questions about how and why this happened. However, if you go the University of Chicago medicine website their two mission statements seem to be "committed, focused, recognized" and "tougher, stronger, smarter." Absolutely nothing about patients, nothing about compassion, nothing about caring. This disconnect between patients and their healthcare is concerning.

Also concerning are the conflicts of interest that seem inevitable in a fragmented healthcare system motivated by profit. The Yale Physician’s Oath 2022 included a “vow to leverage our privilege as physicians to advocate against laws and policies that discriminate against or compromise the health and well-being of our patients.” These are noble sentiments but without action, they mean little. Now is the time for doctors to speak up and act as advocates for their patients and their profession because if they do not then nobody else will. As Kurt Vonnegut put it in the novel God bless you Mr Rosewater, "And they saw that praise was reserved henceforth for those who devised means of getting paid enormously for committing crimes against which no laws had been passed.” Perhaps the time has now come for better regulation of healthcare; time to pass those laws?
Thank you!
Marsha Epstein, MD MPH | Retired
I don't think most physicians know the extent of medical debt in the public and the extent of greed by "non-profit" hospitals. Thank you.
It’s Lack of Regulation
Kathryn Lewandowsky, BSN, RN | Cascade Valley Hospital
This is a great article and I have a lot of respect for Dr. Berwick, but I believe that it is difficult for providers and healthcare professionals to effectively lobby Congress for adequate regulation of the profiteers in health care when many of those companies use our healthcare premiums to “lobby," and I say that loosely, our elected officials. Until that becomes a crime we won’t see the change we need. My union is prohibited from using my union dues from lobbying elected officials, but my health insurance company can use my healthcare premiums?
Greed and Medical Care Do Not Mix - The Former Destroys the Latter
Paul Jacobs, PhD | Psychology, Private Practice

I am reminded of the 1971 movie The Hospital, screenplay by Paddy Chayefsy, which won Academy Awards for Best Screenplay and Best Actor for George C. Scott's performance as Dr Bock, Hospital Chief of Staff. Bock addresses Dr Welbeck, a butcher who has the distinction of losing more patients than any other doctor in the hospital: “You're greedy, unfeeling, inept, indifferent, self-inflating, and unconscionably profitable. Besides that, I have nothing against you. I'm sure you play a hell of a game of golf.”

Nineteen Years
Stacey Kerr, M.D. | Private Practice
In April, 2004, I closed my clinic. I wrote a 'Piece of My Mind' that was published in JAMA explaining why I was closing down (1). This piece is a 'sequel' to mine 19 years later, a span that has only made things more difficult for physicians who are trying to be healers. And the 'What can we do?" section of this article asks providers to do more to save our health care system. I do not see how asking the physicians to do more will be the answer to this problem of greed. Physicians are already doing too much that is contrary to their altruistic motivations to become doctors in the first place.


1. Kerr SM. Keeping the Fire Alive. JAMA. 2004;291(15):1813–1814. doi:10.1001/jama.291.15.1813


Brilliant Articulation of What Ails Our Healthcare
Jerome Stone, RN, CCM | Sedgwick Claims Management
Thank you for this well thought out, and perfectly articulated expose on what ails our healthcare system.

As an RN with over 40 years of experience I fear that the problems driving our healthcare woes, articulated so well in this article, are so deeply systemic and deeply rooted in our economy, Wall Street, and politics, that to dig our way out of this mess will take a multi-pronged, cooperative, and comprehensive restructuring of our healthcare system. And, perhaps cynically after so many years in healthcare, I’m not sure that we have the unity and enough champions within the upper
echelons of the industry and within the government to accomplish such a huge undertaking.

To extricate ourselves from this intertwined spiderweb of profit-driven provision of healthcare will require dismantling a system that relies so heavily on profit, commerce, and investment. We need to disincentivize healthcare for profit. Can we do it? I’m skeptical.

But! Articulation of our challenges, as you presented here, combined with actionable and realistic steps is a good start.

Educating the public is of primary importance, and I think that we often miss this piece when we discuss “how we change healthcare." Until the public begins demanding changes, en masse, and in huge numbers, I don’t think the politicians and legislators are going to do anything to change the present paradigm.

As is evident in the present-day travails and challenges within the political landscape, the will of the people does not come into play in many of the decisions that are made by our political leaders. Legislation panders to the might of the wealthy, who overwhelmingly back and control many of the decisions that are made.

Systemically, I don’t know if we are set up to make significant changes in the economics of healthcare. Will we have to crumble before we can rebuild? Will it have to get so bad that we toss industry-backed candidates out of the roster of electable officials?

Your article is a wonderful start. Perhaps it needs to be mailed to every single individual in Congress. And perhaps we need to unify all of the disparate and many healthcare advocacy organizations and grassroots activists into one unified organization with the numbers and influence to “get sh-t done!”

Thank you for your indulgence of time, and for allowing me to vent my pessimism and cynicism. I so long to be proven wrong!

Warm regards

It's Someone Else's Fault
Stephen Morris, MD | Retired
I have little or no dispute with Dr. Berwick's observations. I believe that much, possibly most, of the financial skulduggery he describes has been enabled by the federal government. I have often wondered why the CEO of a "non-profit " hospital should make 10-20-30 times what the average physician in his/her hospital makes. I have read the explanations of why the same drug should sell in Europe for 1/10 the price it does in the US. The explanations are rather unsatisfying. Perhaps the patent system for drugs needs to be revisited but be aware that part of the cost for this will be fewer new "miracle" drugs.

All my classmates wanted to "save the world" but by about age 35 the fancy car, big house, and boat began to look pretty nice. I doubt if many (any?) of the physicians here advocating the Medicare For All du jour solution felt that they were being paid too much. Some years back when discussing this topic with a physician friend he said "even if we become like the French system we will be pretty well off." Physicians need to accept that cost cutting will come from their salaries not from those of the hospital or pharma CEOs.

The medical malpractice system is a significant driver of healthcare costs.

As far as health care quality being better in Europe or elsewhere this is a game that bean counters play. The Europeans count but they count differently than we do. Just research the definition of a live birth in Europe and the US.

A "Medicare For All" system will not be cheaper or better but it will be different.

Doctors Are Not Immune From the Greed
Jacqueline Hicks Grazette, BA; MBA | Educator, MyCollegeAdvisor
This article does a wonderful job of talking about the problems of lucre in the administration of health care. But the author is light on the role that physicians play in the game. Many are equally driven by profits. We have physicians that no longer even bother to examine their patients, that tell mistruths in their billing and reports, and that themselves offer tests, vaccines, medications, and cosmetic procedures for the sole purpose of income. Medical technicians, PAs, and NPs end up running the practices essentially for them, while the doctor bills for higher fees. />
Covid-19, ownership by big corporations and hospitals, and the desire to concentrate in the "bread and butter" practices of medicine (outpatient surgery by assembly line) has also contributed to greed. Concierge practices abound, leaving the poor and vulnerable to find health care the best they can.

We had insurance reform but we still need health care reform. The American medical system is a failure on preventive and chronic care by any standard. We need to make it easier and cheaper for students to become physicians and begin to alleviate our health care crisis.
Well Done
Maureen Beurskens, MD | Retired
Dr, Berewick has articulated the crisis in the US healthcare system so well. His editorial needs to be shared on every news outlet. Doctors and patients need to rise up.
What Makes Health Care Unique
Charles Silver, J.D./MA. | University of Texas School of Law
From where I sit, greed is a far worse problem in the health care sector than in any other service industry. For example, in no other service sector are fraud, waste, and abuse nearly as serious. And even within the health care sector, fraud, waste, abuse, excessive prices, opaque prices, upcoding, and most other problems are limited to contexts in which third-party payers dominate. In other sectors, markets yoke sellers' greed to buyers' desires for services and products that are good and affordable. They'd do the same in the health care sector if given the opportunity.
We Have Met the Enemy, and It Is Us
Don Gaede, MD | Retired
In my specialty of vascular medicine I have encountered a number of physicians who repeatedly urge their patients to undergo saphenous vein ablations even though these veins by my examination are completely normal. These are often patients who are poor and uneducated and thus are at the mercy of their physician's unscrupulous behavior. Some of them have peripheral arterial disease, and potentially could need these veins for bypass conduits. I have attempted to report one of most egregious offenders to the Medicare fraud center, but so far have been unsuccessful in my attempts.

Then there are the cardiology colleagues
that order annual nuclear scans on my patients—including those who were completely asymptomatic and did not meet any accepted indications for such scans. I finally began arming my patients with literature from Choosing Wisely to take to their next cardiology appointment. The annual tests were scaled back in a number of cases, but this exercise was stressful for me and my patients, who had to challenge the care of their own cardiologist.

Incidentally, Choosing Wisely has an excellent white paper about how vulnerable populations are often the victims not of lack of medical care but of overuse, i.e. unnecessary and sometimes risky procedures pushed upon them by doctors of questionable ethics. 

Multiple surveys show that physician income is not correlated with career satisfaction. One Medical Economics survey showed that pediatricians and psychiatrists, some of the lowest earners among us, nevertheless had the highest satisfaction levels, whereas orthopods’ satisfaction levels were at the bottom of the chart.

Historically, we doctors have been in the top tier of the “noble professions.” This has been attributed to our care for others, our trustworthiness, and our indispensability to society. But if “greed” is added to this list of physician traits, we will quickly lose our noble status not only in the eyes of society but among ourselves as well. Some of this is the result of the fee-for-service system, that incentivizes us for ordering more procedures. Maybe Kaiser Permanente has the right idea.

We physicians need to challenge greed wherever it rears its head, whether it’s pharmaceutical companies, insurance companies, hospitals, or members of our own house. I'm mostly retired now, except for volunteering in a clinic that serves the uninsured at no cost to them. If the upward trajectory of greed-fueled medical costs continues, more and more Americans will be forced to rely on similar clinics of last resort.

Medical Student perspective
Sooyoung Vandemark, MBS | Medical Student
Thank you so much for the Viewpoint article, Dr. Berwick.

As you noted, with nearly half of U.S. adults having medical debt, and nearly half (in Massachusetts) skipping medical care because of costs, it's fair to say that the financial self-interest in US health care already has a stranglehold causing dangerous and perverse outcomes. Sadly, this is not a new phenomenon, but an insidious cancer that we are failing to treat.

Also, I appreciated your recommendations to action. Much of medical school education these days include health system sciences--but the bottom-line of these lessons is that "the
system" is not only necessary, but also efficient and improving patient outcomes. Unfortunately, there seems to be a lack of sincere self-reflection and responsibility at a systems level.