
Diagnosis: Insufficient Outrage - jejune06
http://www.nytimes.com/2013/07/05/opinion/diagnosis-insufficient-outrage.html
======
leetrout
This rings so true. When I had graduated college I was in a 3 week lull
between graduation and a job around January when I was struck with a kidney
stone. No health insurance.

I took a trip to the ER around 10pm one evening in agonizing pain and was
treated like a drug addict. I wasn't even triaged for over 2 hours (peak flu
season) and everyone acted like I was just trying to score pain meds. Finally,
after 3.5 hours, I was sent for a CT and only after the CT confirmed a stone
was I given non-narcotic pain meds (Ketorolac) and send home to wait it out.
Total time in the actual ER was ~1.5 hours (of a >5 hour trip) for a hospital
administered dose of an NSAID only after a CT scan.

$4800.

Took me over 2 years to pay all of it off. It pretty much wrecked my personal
finances (threats from collection agencies finally forced me to put it all on
my credit card). I've been jaded about hospitals ever since.

I've also had another stone in the years since and was diagnosed with a ~$100
sonogram. And I used acetaminophen and ibuprofen to manage the pain for a
couple weeks.

I'm still shocked that I had to wait so long and go through such a costly
imaging procedure to justify a short prescription of a non-narcotic pain
reliever.

I could go on another rant on an intelligent adult not being allowed to order
a simple blood panel for self quantification.

~~~
zanny
I broke my knee this spring but didn't go to a hospital on my families request
because the last time I broke a bone I reset it myself and the hospital still
charged $8k.

I still have blood in the joint, but I can't get it drained because no doctor
will stick a needle in without an x-ray, but those are expensive. So I'm
waiting till I move out and get a full time position in a bigger city to get
health care to have it fixed.

Probably going to have arthritis at 40....

~~~
sentenza
If you know that arthritis is coming, adjust now and move to Germany (or
another similar place). Waiting times for specialists might be a little
longer, but you (=everybody) will be treated for treatable diseases and
injuries. What you have to do, of course, is to move here legally (work
visum?).

~~~
malandrew
How easy is it to move to Germany as an experienced software developer and get
a job there? I know Berlin has a large startup community, but is it large
enough to absorb as many software developers that show up there like it is in
Silicon Valley?

Do you already have to know German or can you get by with learning the
language after making the move?

~~~
sentenza
Although Berlin has more of a reputation, I'd recommend to also consider other
places within Germany. Berlin, while having a lot of startups, is not the
center of the "real" software industry. I recommend taking a serious look at
companies in the Rhein-Main-Neckar region. This region has a cluster of big
software firms, such as SAP, SoftwareAG and the companies working on software
for the financial industry (Frankfurt), as well as Technical Universities
(these are the ones that produce CS graduates).

Be warned, however, that you won't find anything comparable to SV in Germany.
And I have to admit that there is also a problem regarding startups: The
largest cluster of startups is in Berlin, but most of the money in the
software biz is in West Germany. Btw, please don't get scammed by the Samwers.

Experience is definitely a plus, but probably more with the more "traditional"
software companies than with the startups. Many German startups live off fresh
degrees and high hopes (in the sense that they are founded by people out of
the University), with all the positive and negative side-effects that this
brings.

With regards to language, I'd say English and a willingness to learn German
should suffice. Most of the software people already know enough English to
work with them, and some corporations that operate internationally even
mandate some degree of English usage. A few more rules of thumb: If the
company is big or works in an innovative field, English should be all you
need. If, on the other hand, it is located in a rural place or in East
Germany, there might be problems.

These are of course generalizations. In any case, learning German will be
helpful, even if it is only to facilitate the interactions with your
surroundings outside work.

------
bmmayer1
Yes, if prices are skyrocketing it must be a "Crime" caused by all the dirty
capitalists enriching themselves. There could be no possible explanation for
it. Unless, of course, you want to consider:

1) The stifling HIPAA regime that makes it almost impossible for small,
potentially competitive practices to stay open without insane amounts of
overhead, explaining their sellouts to larger at-scale healthcare corporations
2) The necessity to offset insanely low negotiated and subsidized
Medicare/Medicaid rates with bills on the uninsured, thus bifurcating
healthcare recipients into "pays too little" and "pays too much" categories
with no in-between 3) The employer-provided insurance scheme--another
government-subsidized program--which hides prices from consumers and
incentivizes providers to hike up prices 4) Let's not forget about the
inability for insurance companies to hedge risk and lower costs by selling
insurance across state lines 5) Obamacare destroying any potentially new
avenues for innovation by forcing the uninsured to buy into a broken system

What would happen if a doctor or hospital today started practicing medicine at
affordable prices, competitively? What's stopping that from happening? If you
look for what isn't there instead of what is there, you'd see how we've
completely eviscerated any hope of competition, innovation or lower prices in
our system.

The "moral outrage" we should have as Americans is not toward the doctors who
--as even this article grudgingly acknowledges--are good people working in a
bad system. The outrage we should have is toward the captured healthcare-
industrial complex that has a stranglehold on our Congress and President,
using its influence to send more profits its own way at the expense of
patients.

High prices are not a crime. Bad policy is.

~~~
pyre

      | The necessity to offset insanely low negotiated
      | and subsidized Medicare/Medicaid rates
    

My understanding is that insurance companies often get rates lower than
Medicare. It goes something like this:

1) Government mandates the rates for procedure X to make sure that the
government is getting the 'best' deal.

2) Hospitals charge insurance companies using these rates (they aren't allowed
to be lower, or it wouldn't be the 'best' deal).

3) Insurance companies trim the difference between the Medicare rate and the
_real_ rate from the bill with newspeak like, "charge beyond negotiated
rates," or, "over-charge of contractual limits."

It basically amounts to the hospital charging the 'correct' rate, the
insurance company refusing to pay that rate, and the hospital not pushing it
any further since this is all laid out in their formal agreements.

So, I'm not sure if Medicare can be said to have 'insanely low' rates, if the
insurance companies end up with even lower rates. (I'd love for someone to
correct me if my understanding is wrong, though)

~~~
zaroth
As it was explained to me by the CFO of a major hospital, you are incorrect.

Hospitals would be out of of business if their average revenue per procedure
was equal to the Medicare rates per procedure. But that's not to say that
hospitals are "losing money" on every Medicare patient, it's much more
complicated.

Running a hospital is like running an airline, there are extraordinary fixed
costs just to open the doors, regardless if any patients (aka customers) show
up. When you have high fixed and low variable cost, if you are operating below
capacity then the marginal cost to serve 'just one more patient' is low, and
so providing the service at Medicare rates results in net income, all else
equal.

Of course the money for the fixed costs eventually has to come from somewhere.
Right now, that comes largely from private donations, and rate shifting
(higher rates for the privately insured and uninsured).

Simply put it comes down to buying power. No one buys more than Medicare, so
it's not surprising that they get the best rates.

~~~
zanny
> No one buys more than Medicare, so it's not surprising that they get the
> best rates.

It is almost as if a public option might be economically efficient.

~~~
bmmayer1
Not at all, because when you have monopsony pricing you end up below market
price, which drives marginal producers out of business and ends up reducing
supply. It's the same reason the argument for the government buying up all the
food and distributing it doesn't work: because no one would go into a business
where they are guaranteed to make a loss.

~~~
robbiep
Except this isn't the international experience.

In Aus we have a mixed public private system- everyone is treated free but if
you want an elective procedure or to see a doctor of your own choice you can
pay to do so. I have private health insurance and it costs me $1,500 a year
(get dental and optical rebates etc, if I was to require serious treatment it
would cover anything under the sun to be done my way) We have public hospital
elective surgery waiting lists but the upside is people with no money can
actually get the medical treatment they deserve in order to live functional
lives.

I have been involved (as a medical student) in the us system- I know a little
about it- and the creation of 'the medical poor' \- there are probably better
terms for it but basically those unable to get the treatment they need and
thus unable to live their lives as functionally as possible - strikes me as
sad and unjust.

BTW any comment along the lines of 'but doctors don't get paid for their
services so less people will be willing to do it' \- next year I will be
practicing, in 4 years I can expect to be earning $150,000 and in 10-15 I will
expect to be earning $350,000 inflation adjusted. More than enough for a
comfortable life in my chosen specialty

------
p37307
I have seen all of my doctors office swallowed up by hospitals in the last
year. In Southwestern Ohio Mercy Health Systems and TriHealth are buying them
up. They are following the lead of Christ Hospital who started this years ago
at an alarming rate.

As far as my rates go, I did notice almost everything, even items done at the
local office, was an outpatient procedure billed by the mother hospital, at
least in part. Also something I have noticed in the increase in lab work.

I am a chronic patient, I have a heart implant, feeding tube and an infusion
pump that puts baclofen directly in the spinal area.

With co-pays going out of this world under this new system, we have elected to
do many things at home that used to be done at the office. Changing out my
feeding tube used to cost a few hundred dollars and jumped to over $6000 last
fall. My wife now changes it at home. I have my Baclofen pump refilled at home
instead of the office by a third party. I elected to send my heart readings
over the phone instead of going into the office, except twice a year. Finally,
when I make all my appointments within days of each other when possible and
make them share lab results. They don't like this but I can't afford all the
extra charges out of pocket. Even the monthly b-12 shot had a significant rate
increase. Once again, I choose a cheaper route. The local non-affiliated walk-
in clinic for the b-12 shot.

It is nice to see this article. It explains alot. At 41 with a form of
Parkinson's Plus, the nickle and diming has to stop. I don't know where the
$$$ is going to come from.

~~~
xxpor
NE Ohio is the same way. University Hospitals and Cleveland Clinic own
everything. One of the last independant hospitals, Parma Regonal, was
purchased by UH this past week.

~~~
caw
My uncle works for a hospital system that's doing the same "buy up everything"
plan. He says it's because once they own all of the medical providers in the
county, then they will be able to dictate the price to the insurance, instead
of the other way around. What can the insurance companies tell their
customers? Go to the next county for healthcare?

Another relative of mine just merged his surgical practice into the hospital
system's. The overhead on his practice was getting too high, in particular
malpractice insurance.

------
BadCookie
What if every clinic had to make a price list of procedures publicly
available, and could not legally charge people different amounts for the same
procedure (regardless of insurance status and so on)? That would solve at
least some of the problems.

But I think it's obvious that almost no one actually wants to fix the broken
system, because too many people are making too much money from it. (Doesn't
that apply to almost everything in the United States nowadays? It's pathetic.)
I'm happy to see the author pointing the finger at hospitals and doctors. It
doesn't seem like that happens often enough. (When I say "doctors" I really
mean specialists. I don't think that GPs are as much to blame.)

~~~
rquantz
By "almost no one" you mean "probably most people, but some people who make
lots of money from the current system are using part of that money to bribe
politicians not to fix it, and we live under a government where that is
tolerated."

~~~
BadCookie
I suppose I meant "almost no one" who actually has the power to do it. So
yeah, what you said.

------
jeswin
I was visiting the US (from India) a couple of months back. In the hurry to
get to the airport, I forgot to get Medical Insurance. Unfortunately, I got
pink eyes while I was there.

I haven't found America all that much more expensive than urban India. In
fact, compared to cities in India, a few things might even be cheaper. But not
medicine. An eye doctor's visit costs $180, for Pink eyes! A comparable
facility here would have charged me about $8.

I totally get the different standards of living and associated expenses. But
medical treatment stands out so much that I can't imagine how an uninsured
person could afford hospitalization or even moderately complex treatment in
the US.

~~~
xxpor
I think most people just don't go to the doctor for pink eye (including me and
3 other people I know that got it in the past year).

~~~
jeswin
I wasn't planning to either. But buying any medicine requires a prescription
in the US, which may be fine depending on how you look at it.

What I was trying to say was that I found treatment 10x more expensive in the
US; while other expenses are merely higher and generally affordable.

~~~
xxpor
I'm agreeing with you.

We don't get medicine for things like pink eye, we just let it run it's
course.

~~~
cmccabe
now that is silly. you don't know what kind of infection it is unless you go
to the doctor.

You really need to get a health plan if you don't have one. If you're young it
might only be $100/$200 a month, even if you're unemployed.

------
jakobe
I don't get how a cardiac stress test can cost 2000USD. You put someone on a
home trainer, let them pedal for 20 minutes, and look at their EKG. It's
usually performed by a nurse, and the doctor spends 30 seconds looking at the
EKG (the analysis of the EKG is even partially automated).

If there was actual competition on the market, I'm sure a health service
provider would find a way to perform the test for 75USD.

~~~
haldujai
People who have stress tests administered often have underlying cardiac or
pulmonary disorders that can be aggravated.

A not insignificant subset of people doing stress tests can enter into
hypotensive shock or even cardiac arrest, the facility has to be prepared to
deal with adverse effects as those reactions can be fatal.

~~~
lostlogin
Yes - it pays to have a big defib (not one of the 'press button now' mall
variety), an experienced and qualified staff member or 5 with high level CPR
training, and some good cardiac event type drugs, and a load of proper
monitoring gear (heart rate, BP, etc). While these things aren't especially
cheap, they would pay off fairly quickly at a decent clinic, and I was
involved in the purchase of most this stuff for sub $10k US recently for a
clinic (but got a mall style defib as our needs are different). Staff would be
the greatest cost. That said, at 2k per test, most expenses for the year would
be paid of in the first week or 3 at a busy clinic surely?

~~~
haldujai
$2000 isn't that ridiculous depending on the circumstances, but $75 is
impossibly low with America's system. In Canada they bill ~$200 +/\- 100
depending on the details. A comparable figure in the states (again factoring
insurance non-payment issues and convenience factors, i.e. how soon you can
get it, having facilities close by) would be reasonable at $800-$1500.

~~~
vacri
$2000 is utterly ridiculous for a stress test. I used to work as a neurology
tech, mostly dealing with epilepsy. Our tests themselves could invoke
seizures, and we frequently saw seizures anyway, which can be life threatening
if not handled. We were a private department in a hospital - as techs, we knew
enough first aid to keep the person alive and call for the crash cart.

$2000 might sound reasonable if every single patient required emergency
attention, but in truth, far from it. Medical tests aren't meant to bring you
to the brink of death, and are generally designed to keep you safe. It's not
even worth pretending that $2k 'might' be worth it; it's just not. As for
covering for insurance non-payment, isn't that chicken-and-egg? When a test
costs ten times what it should? That would suggest that for each test that
someone pays for, there are nine patients effectively getting it for free.

~~~
haldujai
You're assuming the cost is $200. In Canada it can be up to 6 months (from my
own experience) to get a stress test booking. In the states you can do it the
next week. That gets a significant premium. Compare it to buying something on
eBay from Hong Kong and waiting 5-8 weeks vs paying 4x and getting it right
this second from Best Buy. At the end of the day you're going to get what you
need either way but it's how long you're willing to wait.

$2000 is only for uninsured patients, and as has been demonstrated numerous
times results in you getting shafted when it comes to pricing. A better
problem to attack is reducing the amount of stress tests given, as they're
often completely unnecessary. Ontario has recently decided to stop paying
doctors who give unnecessary stress tests, resulting in ~5000 fewer tests
given every year.

~~~
lostlogin
A good thing about socialised systems (don't get me wrong, there are plenty of
problems too) is that they often have more protocol homogeneity. What this
helps with is that best practice gets codified and protocols written. Then a
clear pathway is made for clinicians to follow, with a review system to allow
for improvements. Fragmented systems with owner operators (usually sub
specialists) can have other motives ($) and little to zero feedback on care
quality. Large systems with set protocols helps reduce unneeded tests. Getting
the money saved put back into other parts of the system however, can be....
Tricky.

~~~
waps
As someone living under a "socialist" system, let me tell you : "practice" is
codified, yes. Best practice is not, unless some politician's kid or granddad
has the disease/condition in question.

Someone I know needed a root canal treatment, and I found out that ... it's
not covered - at all - under the national system. Nor is it covered under
normal insurance except for a small token amount (< $250 equivalent, and yes
it will cost $2k+ here too). And there is no way to get it done quickly, which
makes no sense. We're talking about a root canal here. Delaying it at the
point where it hurts will make things worse FAST. WTF ?

~~~
lostlogin
Hmm.. That's bad. I live in a country with socialised healthcare, and there is
some dental care. Most isnt covered, but if its an accident or an emergency
(such as bad pain), it will get done. Imperfect, yes.

------
batbomb
On the proton therapy: As a particle physicist whose best friend just finished
(photon) radiation therapy for brain cancer, I know a good chunk about this.
First off, not all proton therapy is the same. It's heavily dependent on the
linac and gantry a hospital has. UCSF has proton therapy in Davis or somewhere
targeting glaucoma and stuff, which is completely different than the
facilities at Loma Linda or Massachusetts General. Of higher energy proton
therapy centers, there's only about 5 such facilities in the US. As far as
general hadron therapy goes, there's none. So a proton therapy center in
Washington isn't likely to serve just Washington and/or Baltimore, it's likely
to service Virginia, West Virginia, Maryland, New Jersey, and even farther out
possibly. On top of that, it's still heavily research based, and moving pretty
quickly as we've moved towards modeling human tissue with GEANT4 and Monte
Carlo simulations.

Anyway, while I don't know the specifics of the proton therapy centers
mentioned, the assumption that a proton therapy center would just service
Washington/Baltimore metropolitan areas is silly. After LLNL shut down their
proton therapy center/experiment, we don't even have any proton therapy
centers in the Bay Area.

------
Shivetya
Well look past the hospitals and insurance companies when you want to assign
blame then. The government creates the laws these entities operate under.

Congress knew damn well what would happen when they used the force of
government to compel prices for Medicare/Medicade. Insurance companies got on
the ride because of size. Yet it falls to Congress to be the one to look out
for the little guy but that was not their concern. Their concern was to
maintain the steady flow of campaign contributions.

The ACA was more of a payoff to insurance and hospital industries than looking
out for the public. The reason why most members didn't read the bill is
because its contents were not important, its effect on their position was what
mattered.

For years Federal law has prevented people from shopping across state lines
for medical insurance. For years it has been adding elective treatments and
surgeries as requirements to even the simplest policies which in turn reduced
their affordability.

The solution, try to put everyone in the pool by force of law and reap the
rewards of insurance companies and hospitals suddenly with more business than
they had means to process.

------
haldujai
A large portion of this cost is because some people don't pay, and they can
run huge tabs. Meidicine is a business, and that cost has to be shifted to
other patients to compensate.

In socialised systems, like Canada, physicians actually make more money
because the government always pays so it's not a greed issue. The downside is
that the government has limited funds, so the amount of beds, ORs, and
advanced equipment is severely limited and wait lists are rediculous, ER times
between 6-8 hours, chemotherapy wait lists of 8 months, surgeries 1 year + for
the worst of surgeons. Alberta is the exception as they have rediculously deep
pockets from oil revenue.

It's a trade off, this is a case of you get what you pay for. Free healthcare
only works when the state has money to blow on quality care, I.e Texas with
the Scottish Rite hospital.

You can't directly compare life expectancies with the US and places like
France (which have free or near free healthcare) and conclude that it is just
as good, if not better than America's. There are many confounding variables
here (I.e their very short work weeks).

------
Qantourisc
Seriously, just copy the EU on healthcare. You might need to pay extra taxes,
and take an extra insurance against hospitals fees. But it's all very
affordable.

If it wasn't for A) getting the same answer for most of my ills: inflammations
:p B) The doctor being very busy. C) Basic respect to not stress our medical
system. One would go for the tiniest medical complain.

~~~
loginalready
The EU is not a country. The EU has no single healthcare system.

Every country has it's own system, which range from anything between 100%
government provided to mostly privatized. No system is the same. And it's not
just the EU, it's the entire Western civilization outside the US.

This is extremely important, because the healthcare debate in the US is
falsely framed as a choice for or against "socialized medicine", were in
reality socialized medicine is a rarity amongst the various healthcare
systems.

Whether or not to make quality healthcare accessible to everyone is not an
ideological choice, the problem can be solved within the framework of any
political ideology.

It's strictly a choice between decent healthcare for everyone or bigger
profits for the healthcare industry.

~~~
alan_cx
As I understand it, there sort of is the same health care across the EU. There
is an EU healthcare card which means any EU citizen gets treated in any EU
country. The systems are different, but in the end we can all get healthcare
free at the point of delivery. No absurd bill.

The details of how each country does it are different, but the result is the
same. No insane bills to stay alive. No poor turned away or treated like
second class citizens.

I have to say, of all the things I cant get my head round about the US, the
health care system is the biggest jaw dropper for me. Not only is it not
universal, but the people who run it make incredible profit out of it. Seems
mad to me.

~~~
Someone
Health care and health care insurance approaches are not the same across the
EU, but the EU does proscribe that residents of any EU (1) country insured in
one country get medical treatment in any other country
([http://en.wikipedia.org/wiki/European_Health_Insurance_Card](http://en.wikipedia.org/wiki/European_Health_Insurance_Card))

(1) as always, there are zillions of EUs to choose from. Reading the Wikipedia
page, it actually isn't the real EU, but the EU plus (all?) members of the
EFTA.

------
abraham_s
How much does the Affordable Care Act addresses this? I know insurance can't
be denied to people with pre-existing conditions and there can't be any life-
time expense caps. But is there any measure to address the high cost of health
care in US?

~~~
zanny
Effective next year up to 400% of the poverty line is eligible for some
fraction of their expenses covered under Medicaid. If you are beyond that
threshold is the infamous "uninsured tax". Note that 400% of the poverty line
is around $50k a year.

~~~
mathgladiator
I wonder where the 400% came from; that seems very... odd

~~~
zanny
The poverty line is a sliding scale based on household size, so for a 4 person
household that threshold is 94,200. It is basically the "you make enough money
that you can either get insurance through work or the flat rate we are forcing
insurers to pay".

------
xentronium
Here, in Russia, basic medical assistance is mostly free (or costs peanuts
compared to US), but on the flip side you have to sit through enormous queues,
talk to incompetent doctors and doctors themselves might extort you. Paid
medicine is better and sometimes better qualified, and you get better service,
but it's totally out of budget for anyone below middle class.

Good news is that you won't be charged bajillion dollars after you broke your
hand, bad news is that you'll have to wait and suffer in horrible insanitary
that is Russian polyclinic.

I have mixed feelings about our health care system. I believe, it will
gradually disintegrate as doctors from soviet era get older and retire.

------
bit_cromwell
Prescription: Free Market Competition

~~~
namlem
Why don't you elaborate instead of just yelling "free market!" and waving your
hands? How might we encourage competition effectively?

~~~
noonespecial
No one can open a new, competing hospital without the permission of the lousy
overpriced hospitals that its intended to compete with.

Yes, you need your _competitor 's permission_ to enter the market. Its the
law.

[http://en.wikipedia.org/wiki/Certificate_of_need](http://en.wikipedia.org/wiki/Certificate_of_need)

