In his book “Mistreated,” Robert Pearl, M.D. talks about the four “legacy players,” that resist needed change in our dysfunctional, expensive healthcare system—because they benefit financially from the status quo. These entities are hospitals, medical insurance companies, physician specialty societies, and the pharmaceutical/medical device industry.

Last year, Elisabeth Rosenthal, M.D., wrote the book “An American Sickness, How Healthcare Became Big Business and How You Can Take It Back.”  She writes about how in the last 25 years “healthcare, the caring endeavor, became healthcare, the highly profitable industry,” and about how “our politicians have proven themselves either unwilling or unable to rein in the increasingly outrageous costs faced by patients.”

In regard to hospitals, Dr. Rosenthal notes that “from 1997 to 2012, the cost of hospital services grew 149 percent, while the cost of physician services grew 55 percent. The average hospital cost per day in the United States was $4,300 in 2013, more than three times the cost in Australia and about ten times the cost in Spain.” Following are a few of Dr. Rosenthal’s thoughts on how hospitals contribute to the high cost of medical care in this country:

• Based on advice from consultants, hospitals– including nonprofits– boost charges as much as they can on whatever they can, including operating room time, oxygen therapy and drugs (note that usually hospitals won’t let you take your own medications during your admission). We all have experienced—or known others who have—outrageous hospital charges, such as $48 for putting an oximeter on a patient’s finger for a few seconds to check pulse rate and oxygen saturation (the device costs less than $50 at Walmart, is reusable, and lasts for years)–or $17 for an acetaminophen tablet which costs well under a penny.
• In a section of the chapter on hospitals titled “closing departments: make money or die,” Dr. Rosen notes that “hospitals…enhanced their most profitable offerings:  orthopedics, cardiac care, a stroke center (revenue from expensive scans), and cancer care (revenue from infusions)” while closing departments that aren’t very profitable, even if they benefit patients.
• In talking about “the emergence of hospital-hotels,” Dr. Rosenthal notes that 25 years ago rooms with four beds were common, but now single rooms are the norm, even though “there is little medical justification and many insurers won’t cover them.” A health economist quoted by Dr. Rosenthal says hospitals are “like Four Seasons Hotels, with valet parking and chandeliers.” (The book doesn’t mention fireplaces in the rooms, probably because readers wouldn’t believe that such a hospital exists).
• Many hospital CEOs are paid exorbitant salaries, even if the hospitals they manage are nonprofit. “An American Sickness” notes that “in most cities the highest-paid nonprofit executive by far runs the local hospital.”
• Putting an E.R. patient on observation status while getting tests to determine the diagnosis and need for admission made sense in the past, before modern diagnostics such as CT scanning became available. Many hospitals now abuse the system: Rosenthal explains that “the easy money for Medicare patients is not in inpatient admissions. Medicare pays a bundled rate for those. But outpatient care has no similar limits–the till is open for testing.”
• Many hospitals, especially community hospitals, are nonprofit, which allows them to receive huge tax benefits. They hire consultants and accountants to figure out how they can maintain their nonprofit status while doing the minimal amount of required charity and community benefit work.

At the end of her book Dr. Rosenthal has a section that lists the following sites you can use to vet hospitals in your area:

• New York Times Pricing Calculator: nytimes.com/interactive/2013/05/08/business/how-much-hospitals-charge.html. This tells you how much a particular hospital charges for various procedures, the Medicare hospital payment for admissions for conditions such as pneumonia, and how much more than the Medicare rate the hospital typically bills patients.
• The Leapfrog Group: leapfroggroup.org/ratings-reports.  This rates hospitals on several quality measures.
• Hospital Compare: medicare.gov/hospitalcompare/compare.html. This site is run by Medicare and rates hospitals on quality measures including those related to particular procedures.
• Propublica Nonprofit Explorer (https;//propublica.org/nonprofits) and Guidestar (guidestar.org) “allow you to download an IRS Form 990 for most hospitals.” For a nonprofit such as Valley View Hospital, these sites include the compensation of the hospital’s highest-paid executives and doctors, what they claim as charitable work, and what the profit was every year.