Doctor burnout is costing the U.S. health care system a lot — roughly $4.6 billion a year, according to a study published this week in the Annals of Internal Medicine.

“Everybody who goes into medicine knows that it’s a stressful career and that it’s a lot of hard work,” says Lotte Dyrbye, a physician and professor of medicine at the Mayo Clinic in Rochester, Minn., who co-authored the study.

She says the medical profession now carries an increasing load of paperwork and bureaucracy, adding stress to doctor’s lives. “We want to be able to deliver good quality care to our patients, and our systems get in the way,” Dyrbye says.

The study defines burnout as substantial symptoms of “emotional exhaustion, feelings of cynicism and detachment from work, and a low sense of personal accomplishment.” This description tracks closely with the World Health Organization’s newly updated definition for burnout.

To put a price on burnout, the study authors culled data from recent research findings and reports — including direct or inferred findings on doctors cutting back on hours or quitting as a result of burnout. They ran a mathematical model to estimate the costs associated with burnout, focusing on the costs of replacing physicians and lost income from unfilled positions.

A previous study, which shares some of the same authors, found that 54% of doctors reported experiencing at least one symptom of burnout, from the Maslach Burnout Inventory, a validated tool for measuring burnout.

Dyrbye says research shows that doctors find meaning in helping patients but are taxed by systemic burdens they consider tangential to patient care. “Cumbersome, inefficient” electronic health record systems; increased reporting requirements; and hectic, irregular schedules cause doctors to feel that they’re socially isolated and lack autonomy.

“There is a general sense of loss of meaning [to the work],” she says.

The study authors calculate that for health care organizations, the cost of burnout comes out to $7,600 per physician per year. The study notes that their cost estimate is conservative, only taking into account lost work hours and physician turnover. But other research shows burned out doctors are also more likely to make medical mistakes, have less satisfied patients, and get sued for malpractice, all of which have indirect costs.

Constance Guille, a doctor and associate professor at the Medical University of South Carolina, who was not involved in the study, says that highlighting the economic costs associated with burnout is important work. However, she says, a weakness of the study is that it drew from inconsistent data, an issue baked into the literature: “We’re not actually able to measure burnout well,” she says.

Guille co-authored a paper, published last year in JAMA, that found at least 47 definitions of “burnout” across 182 studies. From Guille’s perspective, mental health diagnoses offer clearer metrics.

“Burnout is highly, highly associated with major depression,” she says. “It’s measurable, and we have really good interventions for it.” She adds that focusing on depression “could improve physician health, and reduce the financial impact of burnout.”

The current study is accompanied by an editorial also published in the Annals of Internal Medicine by Edward Ellison, executive medical director of Southern California Permanente Medical Group, a health care provider in the Kaiser Permanente network that employs over 8,500 physicians.

He writes that burnout is associated with “anxiety, depression, insomnia, emotional and physical exhaustion, and loss of cognitive focus.” But most concerning, Ellison notes, is that the physician suicide rate is much higher than the general public’s and even exceeds that of combat veterans. “[W]e cannot underestimate the urgency, severity, and tragedy of the human cost,” he writes.

Doctor burnout has been a known problem for years, the study authors note, and by putting a cost to the problem and using the language of policymakers and CEOs, they aim to compel organizations to act.

“We hope that people will think about these numbers and say: ‘If I invested half that amount of money in systems that improve work efficiency, or ways to build better teams to offload some of the workload from the physician, not only is it the right thing to do, but it’s also going to improve my quality and safety, and save me some dollars in the end,'” says Dyrbye.

Bottom line, she says, addressing burnout is not just a moral responsibility: It could also be money-saving.

Pien Huang is NPR’s Reflect America Fellow, helping to bring more diverse voices to air and online.

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As rural hospital closures roil the country, some states are banking on a rescue from a Trump administration proposal to change the way hospital payments are calculated.

The goal of the proposal, unveiled by Centers for Medicare & Medicaid Services Administrator Seema Verma in April, is to bump up Medicare’s reimbursements to rural hospitals, some of which receive the lowest rates in the nation.

For example, Alabama’s hospitals — most of which are rural — stand to gain an additional $43 million from Medicare next year if CMS makes this adjustment.

“We’re hopeful,” said Danne Howard, executive vice president and chief policy officer of the Alabama Hospital Association. “It’s as much about the rural hospitals as rural communities being able to survive.”

The proposed tweak, as wonky as it may seem, comes with considerable controversy.

By law, any proposed changes in the calculation of Medicare payments must be budget-neutral; in other words, the federal government can’t spend more money than previously allocated. That would mean any change would have a Robin Hood-like effect: a cut in payments to some hospitals to make it possible to increase payments to others.

“There is a real political tension,” said Mark Holmes, director of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. Changing the factors in Medicare’s calculations that help hospitals in rural communities generally would mean that urban hospitals get less money.

The federal proposal targets a long-standing and contentious regulation known in Washington simply as the “wage index.” The index, created in the 1980s as a way to ensure that federal Medicare reimbursements were equitable for hospitals nationwide, attempts to adjust for local market prices, said Allen Dobson, president of the consulting firm Dobson, DaVanzo & Associates.

That means under the current index a rural community hospital could receive a Medicare payment of about $4,000 to treat someone with pneumonia while an urban hospital received nearly $6,000 for the same case, according to CMS.

“The idea was to give urban a bit more and rural areas a bit less because their labor costs are a bit less,” said Dobson, who was the research director for Medicare in the 1980s when the index was created. “There’s probably no exact true way to do it. I think everybody agrees if you are in a high-wage area you ought to get paid more for your higher wages.”

For decades, hospitals have questioned the fairness of that adjustment.

Rural hospitals nationwide have a median wage index that is consistently lower than that of urban hospitals, according to a recent brief by the Sheps Center. The gap is most acute in the South, where 14 of the 20 states that account for the lowest median wage indexes are located.

Last year, the Department of Health and Human Services Office of Inspector General found that the index may not accurately reflect local labor prices and, therefore, Medicare payments to some hospitals “may not be appropriately” adjusted for local labor prices. More plainly, in some cases, the payments are too low.

In an emailed statement, Verma said the current wage index system “has partly contributed to disparities in reimbursement across the country.”

CMS’s current proposal would increase Medicare payments to the mostly rural hospitals in the lowest 25th percentile and decrease the payments to those in the highest 75th percentile. The agency is also proposing a 5% cap on any hospital’s decrease in the final wage index in 2020 compared with 2019. This would effectively limit the loss in payments some would experience.

Dobson, a former Medicare research director, said he expects “enormous resistance.” (The CMS proposal is open for public comment until June 24.)

HHS Secretary Alex Azar, foreshadowing how difficult a change could be, said during a May 10 Senate budget hearing that the wage index is “one of the more vexing issues in Medicare.”

It’s problematic, agreed Tom Nickels, an American Hospital Administration executive vice president, noting in an emailed statement that there are other ways “to provide needed relief to low-wage areas without penalizing high-wage areas.”

It’s this split that appears to be dictating the range of reactions.

The Massachusetts Health & Hospital Association’s Michael Sroczynski, who oversees its government lobbying, questioned in an emailed statement whether the wage index is the correct mechanism for providing relief to struggling hospitals. The state’s hospitals have historically been at the higher end of the wage index.

In contrast, Tennessee Hospital Association CEO Craig Becker applauded the proposed change and said the Trump administration is recognizing the “longstanding unfairness” of the index. Tennessee has been among the hardest hit with hospital closures, counting 10 since 2012.

In Alabama, where four rural hospitals have closed since 2012, Howard said that without the change she “could see a dozen or more of our hospitals not being able to survive the next year.” Indeed, Howard said, hospitals in more than 20 states could gain Medicare dollars if the proposal passes and “only a small number actually get hurt.”

Kaiser Health News asked the Missouri Hospital Association, in a state where most hospitals do not stand to gain or lose significantly from the rule change, to calculate the exact differences in hospital payments under the current wage index formula.

Under the complex formula, a hospital in Santa Cruz, Calif., an area at the top end of the range, received a Medicare payment rate of $10,951.30 — or 70% more — for treating a concussion with major complications in 2010 as compared with a hospital in rural Alabama, at the bottom end, which received $6,441.76 to provide the same care.

Even more, MHA’s data analysis showed that the lower payments to Alabama hospitals have compounded over time. In 2019, Medicare increased its pay to the hospitals in the area around Santa Cruz for the same concussion care. It now stands at $13,503.37 — a nearly 23% increase above the 2010 payment. In contrast, rural Alabama hospitals recorded a 3% payment increase, to $6,646.80, for the same care.

For Alabama, addressing the calculation disparity could be “the lifeline that we’ve been praying for,” Howard said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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When the first HIV drug, AZT, came to market in 1987, it cost $10,000 a year.

That price makes Peter Staley laugh today. “It sounds quaint and cheap now, but $10,000 a year at that time was the highest price ever set for any drug in history,” he says.

At the time, the price Burroughs Wellcome set for the drug sparked outrage. The AIDS epidemic was an urgent national crisis. For many, the diagnosis was a death sentence. The TV-viewing public was horrified by endless images of young men, suddenly sick and dying. A lost generation.

ACT UP — the AIDS Coalition to Unleash Power — was established by Staley and others to drive government attention and research toward a cure. A key early goal of the movement: force down the price of AZT. Whatever it took.

“I led an action where we invaded [Burroughs Wellcome] headquarters in April of 1989 and sealed ourselves into a third floor office and caused $9,000 of property damage,” Staley says. “In September, we infiltrated the New York Stock Exchange before the opening bell with fake IDs and got into a VIP balcony and unfurled a banner that said ‘Sell Wellcome,’ and set off Marine fog horns that drowned out the opening bell. And we threw out fake $100 bills to the traders below us.”

He can’t quite remember, but thinks the fake bills read, “F*** your profiteering, we die while you play business.”

“The company lowered the price another 20% three days after that,” Staley says.

Because of ACT UP’s effectiveness, he says, the price of AZT went from $10,000 a year to $3,200 a year. “We were a major news story back then,” he says. “And that was essential to all of the victories that we had.”

Now, AIDS activists — drawn from that older generation, and from a new one — are working again to bring down the prices of HIV medication. This time, the drugmaker is Gilead Sciences, and the drug is Truvada. It’s the only FDA-approved version of PrEP, which stands for pre-exposure prophylaxis, currently available commercially in the U.S.

The list price? $1,780 a month, or $21,360 per year — more than 350 times the cost of generic versions of the drug available in most other countries.

“There are remarkable parallels to what’s happening with Gilead these days,” Staley says. “We are back to the Burroughs Wellcome days, where we have one company — we have a monopoly dominating the market and raking in money for what are actually government inventions. And we’re having massive access issues because of it.”

Still, the issue is playing out in a different era, Staley notes, and that’s requiring new tactics from advocates for patients.

“AIDS is an old story now,” he says. “That’s our new reality. So we accept it and we work around it.”

Today, though the HIV epidemic is quieter, it’s still deadly. People can live long lives with the virus, but there’s no cure, and it continues to spread. Gay and bisexual men, African Americans, Latinos and people living in the South are especially at risk.

Staley is now part of PrEP4All — an offshoot of ACT UP. The group was launched last summer, but is ramping up its activity now in light of the Trump administration’s plan to end the spread of HIV in America by 2030. That goal can only be reached if more people get on the PrEP regimen — currently only a fraction of the 1.1 million people at significant risk for getting HIV are taking the daily prevention pill.

To meet this new moment, Staley says, PrEP4All activists are using some of the same broad tactics as ACT UP, but also increasing their activity behind the scenes. They’re showing up in front page articles and editorials, at pharmaceutical shareholders meetings and publicly confronting officials in the Trump administration. They have a petition and a hashtag and a white paper — and have harnessed the tools of social media to help hold elected officials accountable.

“We have a congressional strategy, and we have what ACT UP never had — a legal strategy,” Staley says. “We’re working with deep-pocketed law firms, which is totally something that ACT UP never thought to do.”

He credits the young activists who are part of today’s movement for that new approach. “The sophistication by the millennial activists that I’m working with today has my head spinning,” Staley says. “They’ve got this historical template that says, ‘Anybody can do this. You just have to have the willpower and the self-confidence.’ They’re absolutely on fire — they already are making changes and they will continue to.”

The public “disruptions” PrEP4All has engaged in recently — along the lines of those ACT UP was known for — generally fall into two categories: shaming Gilead into voluntarily lowering the price of Truvada, and pressuring the government into challenging Gilead’s patent of the medication, so generic competition might force the price down.

“Our goal is to get Gilead Sciences to release the patent,” says Emily Sanderson, a co-founder of PrEP4All and one of the millennial activists Staley mentioned. “Gilead has the power to make PrEP available right now for everybody and they’re not doing it,” Sanderson says.

In mid-May at a congressional hearing focused on the price of Truvada, PrEP4All activist Dr. Aaron Lord made a personal appeal to Gilead CEO Daniel O’Day in front of lawmakers.

“Mr. O’Day, why not lower the price of Truvada to $15 a month, right here, today, at this hearing?” Lord asked. “We look to you today to ensure that every single person in this country can protect themselves from this plague.”

O’Day did not respond to that appeal. Instead, throughout the hearing, he explained the company’s rationale.

“The pricing set in the United States takes into account the innovation it brings, the cost of the health care of treating an HIV patient, [and] the ability to invest back in research and development,” O’Day said. He also said the company was working to “make sure our access programs are effective” so that price was not a barrier for patients.

From Gilead’s perspective, Truvada is under patent for a limited time and shareholders want to see profits. Gilead also argues the price isn’t the problem — lack of awareness, stigma and homophobia are the problems.

Gilead also points out that relatively few patients have to pay the list price. The company provides the drug at a discount to government programs; it just donated some 2.4 million bottles of Truvada a year to the Centers for Disease Control and Prevention to cover some uninsured patients; and it has a copay assistance program for people with high deductibles.

PrEP4All activists are generally dismissive of these efforts.

“They’ll highlight their access programs. They’ll highlight the ways that some folks are covered. But there are so many gaps,” says activist Jake Powell, who takes PrEP. “And I personally fell through one of those gaps.” The gap occurred when Powell’s high-deductible insurance plan, which had accepted Gilead’s copay assistance for one year, stopped counting the payments towards the deductible the second year.

“I was off [PrEP] for about six months because I couldn’t afford it,” Powell says.

The activists are also focused on the government’s role in allowing the price of Truvada to stay high. “The CDC can come in and reduce the cost of PrEP and provide it at an affordable price,” Sanderson argues.

PrEP4All makes two points on this front. The first, detailed in a recent investigation by The Washington Post, is that the CDC has its own valid patents for PrEP that the agency could be enforcing (something Gilead disputes) and that taxpayer money was used in the studies underlying Gilead’s Truvada patent. Secondly, the activists argue, the government has the power under the Bayh-Doyle Act of 1980 to “march in” and break Gilead’s patent in the name of public health, so that competition from generics could bring the price down.

So far, neither the CDC nor Gilead have shown signs, at least publicly, of being moved by PrEP4All’s arguments. I ask Peter Staley if that lack of response from Gilead and the CDC is discouraging.

“The patent issue is very much bubbling at a boil right under the surface,” Staley says. “It’s not visible to the public, but it is a raging issue. And there are Democrats on both the House side and the Senate that want answers and are not going to let this go.”

He pauses, then adds: “We won’t let them let it go.”

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