
Ask HN: Xray cost – USA $200 (13000 INR), India 1000 INR – what causes 10x diff? - user-on1
https:&#x2F;&#x2F;www.medifee.com&#x2F;treatment&#x2F;dental-xray-cost&#x2F;<p>http:&#x2F;&#x2F;health.costhelper.com&#x2F;dental-x-ray.html<p>Why would a full mouth xray cost be this different, there may be some difference in few aspects but what adds up to more than 1000% difference?
======
chadash
The xrays are probably almost identical. The difference is that dentists
simply charge much more in the United States. The median dentist salary in the
US is about $150,000 [1]. In India, the median dentist salary is 344,000 INR,
or about $5,250.

Some of this can be attributed to general differences in labor costs between
the US and India. With few exceptions, most service industries in India are
going to charge less because it's not as wealthy of a country. However, the
biggest difference is that Americans are simply used to paying absurd amounts
for medical care of any sort. There are a variety of factors at play,
including strict limits on the number of dentists graduating each year, dental
insurance coverage (most dental insurance plans cover x-rays, so people with
insurance tend not to consider the cost), etc.

[1] [http://www1.salary.com/Dentist-
Salary.html](http://www1.salary.com/Dentist-Salary.html) [2]
[https://www.payscale.com/research/IN/Job=Dentist/Salary](https://www.payscale.com/research/IN/Job=Dentist/Salary)

~~~
zaptheimpaler
It doesn't make sense to compare salaries between US & India on a US$
perspective. Indian salaries are lower in terms of USD, but the cost of living
is also lower - basically the 5$ USD meal at McDonalds in US costs maybe 1$
USD in India. If you are paid "less", but everyone else is paid "less" too,
then goods/services are cheaper - so the actual goods/services you can
purchase will be the same for a much lower salary in India. Lookup purchasing
power parity.

It might be more sensible to compare how much more dentists make than the
average income. i.e Average dentists salary / average salary.

For US I get - 175350/55775 ~ 3x

For India its 8.5x

So dentists are probably pretty well paid in terms of the standard of living
they can purchase.

~~~
potlee
It does make sense to compare them on a USD basis if you trying to figure out
what causes a 10x difference in x-ray cost between the U.S. and India (in USD)

~~~
zaptheimpaler
Read up on purchasing power. Purchasing power is what your money can buy,
which is the more correct measure.

Its the same reason it doesn't make sense to directly compare programmers
salaries in San Francisco vs. Pittsburgh. If (made up numbers) 120K$ in SF
buys the same lifestyle as 90K$ in Pittsburgh, it means someone making 120K in
SF is roughly as wealthy as someone making 90K in Pittsburgh. Certainly saying
that the SF programmers make 1.3x more is true, but the more fundamental
question is the lifestyle that the income affords you.

~~~
jogjayr
Kinda-sorta. With a higher salary, living a below-average lifestyle for the
area can lead to staggering savings rates and savings in absolute terms. For
instance, saving even 23% of 120k is better than saving 30% of 90k.

And of course a lot of things cost the same regardless of where you live.
Manufactured goods cost pretty much the same in India as in the US and
sometimes more, because of import duties. Gasoline is significantly more
expensive.

~~~
zaptheimpaler
Right.. now going back to the India/US comparison, its pretty fair to say 99%
of people in India will not immigrate to the US. So the hypothetical value of
saving lots of money in the US to spend in India doesn't really apply. The
SF/NYC analogy does not hold exactly to US/India.

~~~
jogjayr
Who said anything about saving in the US to spend in India? Saving in the Bay
Area to spend in rural Montana is an equally valid comparison, cost-of-living
wise.

The point I was making is that some things cost the same no matter where you
live. The Indian dentist who wants to take a foreign vacation, buy an iPhone,
or a car needs to spend more, relative to her income, than the American
dentist. Purchasing power only holds for things that are labor-bound (mainly
services, and goods that are labor-intensive to manufacture) rather than
resource-bound.

~~~
zaptheimpaler
Purchasing power is based on a basket of goods for the average consumer. It
takes into account expenses like phones and cars - as you say, iPhones are
still expensive but the basket would take that into account and purchasing
power would be lowered accordingly.

------
golfstrom
Medical providers in the US do not compete on price. There is in general
little to no price transparency, as everything is traditionally paid for by
private insurance. So as a rule, dentists will charge the maximum allowed by
private insurance for x-rays.

In the US, people are complaining more and more about the cost of healthcare,
but usually in terms of the cost of insurance. They never ask why providers
charge what they do (p.s. - if you're in the hospital, don't ask your nurse to
bring you a tissue, just buy some from the gift shop).

~~~
KGIII
As I have mentioned before, you don't expect your automobile insurance, even
full coverage, to pay for a tuneup. Expecting medical insurance to pay for
regular care is just inserting a middleman that extracts value while
increasing costs and adding no benefit.

Of course, this means people would have to pay for their regular care and
visit the doctor on schedule.

The reasonable alternative is single-payer health care. Insurance is for
catastrophic things, not for regular maintanence. Using it to pay for penis
pills and birth control only makes it more expensive. Pushing for insurance to
cover more things is only making the fees go up and their profits greater.
Insurance shouldn't cover your regular checkup.

And, as stated, single-payer appears to be the only rational solution.
According to the vast amounts of evidence, it is even less expensive on the
whole society AND has better overall outcomes. Those of us with money will
still be able to pay for extra care, there would still even be an insurance
industry.

~~~
alexanderstears
>The reasonable alternative is single-payer health care. Insurance is for
catastrophic things, not for regular maintanence. Using it to pay for penis
pills and birth control only makes it more expensive. Pushing for insurance to
cover more things is only making the fees go up and their profits greater.
Insurance shouldn't cover your regular checkup.

I really hope that the dissident right and progressives can team up on this.
We can offer every American access to quality, cost effective, non-
discretionary care for less than we currently spend on the ACA's contorted
cross-subsidy and insurance profit guarantee scheme.

We could offer everyone access to no-cost healthcare and cap the expenses at
something like 10% of our GDP with a fully empowered rationing feature that
gives us the best QALYs for the money. We'll have to fight past the views of
extremists but it would go a long way to making the U.S a better nation.

And it would permit a separate completely private, minimally regulated
healthcare system for those who wanted it.

------
simonh
This summer I was in China as my wife is Chinese and everybody was complaining
how expensive everything is these days. The thing is salaries in China have
gone up hugely as well and that is mainly why prices have gone up. If the
workers in a factory are paid 5x as much as 15 years ago, the lorry driver
taking the goods to the shop is paid 5x as much, the shop assistants are paid
5x as much, etc, etc then the goods sold in the shop are pretty much going to
have to cost 5x more than they used to.

Same thing here. The rent on the dentists office costs more, the dentist is
paid more, the utility bills cost more, medical practitioner insurance costs
more, the receptionist is paid more. You can’t have many times higher salaries
in the US and not expect things to cost more than they do in somewhere like
India.

~~~
wonderous
Household income for the average house hold has not increased that much:
[https://www.advisorperspectives.com/dshort/updates/2017/09/1...](https://www.advisorperspectives.com/dshort/updates/2017/09/19/u-s-
household-incomes-a-50-year-perspective)

~~~
simonh
I was talking about China as an example of how average wage increases, in
China, are linked to changes in the prices of goods and services. So just as
these things are different in China between then and now, so we can see that
these factors can affect prices in India versus the USA or other western
countries (I live in the UK).

------
galadran
More appropriate comparison would be to the UK where the cost of a private
dental X-ray is between £9-£14 ($14-$22) [1], although realistically you would
want a consultation as well. Most Brits use the NHS (state socialised) which
provides a checkup and treatment for ~£20 for simple cases including x-rays
[2]. Note that [2] is costs for an entire treatment which might be multiple
visits and laboratory work.

[1]
[http://www.whatclinic.com/dentists/uk/x-ray](http://www.whatclinic.com/dentists/uk/x-ray)
[2]
[http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Dentalcosts.a...](http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Dentalcosts.aspx)

~~~
shoo
The nhs seems fairly impressive & well regarded internationally.

That said, anyone have some data on the quality of dental work done in UK
system vs that of other countries?

Anecdotally i know a couple of people who lived in UK and moved to Australia
have been pretty excited* about being able to access higher quality dental
care to repair / mitigate earlier work done in the UK.

* well, as excited as one can reasonably get about expensive, painful, time consuming dental work...

~~~
dnel
The dentist doing surgery under the NHS will be the same one doing a private
appointment afterwards. The only difference is the price you pay after, not
the quality of the work. Each dentist typically has a limited number of NHS
patients on their books so it can be pretty hard to find one available NHS
spaces but private dental is not expensive.

------
robocat
$30* for dental x-ray in New Zealand (private system).

NZ has first world dental care. The price is from 2013, but straight
conversion to USD will approximately offset inflation.

Dentist's salary guideline: [https://www.careers.govt.nz/jobs-database/health-
and-communi...](https://www.careers.govt.nz/jobs-database/health-and-
community/health/dentist/about-the-job)

[*] [https://www.consumer.org.nz/articles/dentists-
fees](https://www.consumer.org.nz/articles/dentists-fees)

~~~
user-on1
What happens behind the screen where one country is able to groom healthy
medical/ insurance system and other countries get infected with so called
insurance systems. Is it about the consumers being weak or is it about the
service providers being strong?

~~~
sitharus
I think it's due to relative power of the consumers. In most medical and
dental situations the consumer does not have a lot of power compared to the
providers. A government-lead system can drive down to the cost of providing,
eliminating the profit consideration.

In New Zealand dental work is almost entirely private, there's no government
backup for most people (there's an exception for basic work for those on low
income).

On the other hand dental insurance is almost unheard of so clinics can't ask
for too much. Last time I had a checkup, 2 xrays and a clean and polish it
came to NZ$160 and that wasn't at a cheap practice. Also removal of two upper
wisdom teeth was NZ$2500 including sedation.

It's been noted above that NZ doesn't require malpractice insurance due to the
presence of ACC so this probably has a material impact on the prices.

------
bastijn
My (somewhat educated) guess:

1\. Hospital staff bills less per hour

2\. They typically run cheaper systems (not top of the line but specifically
made for India/Asia or refurbished. Can be up to 1/3rd of costs of western
world system.

3\. They typically keep their systems longer and have more exams to earn back
their system costs.

4\. Service licenses are cheaper due to labor costs. (24/7 support is cheaper
in India)

It not much different from why other costs of living are cheaper in India
really.

By the way. A lot of people go to private clinics where the differences are
much less. More like 1/4-1/5th of the price.

~~~
gorbachev
5\. Greed

The healthcare industry in the US operates on the principle maximizing
profits. They excel at it at the expense of patients who have limited choices
to comparison shop and/or choose their healthcare providers.

Case in point. My daughter ripped up her lip pretty bad several years ago. It
required immediate stitching to repair. At the recommendation of our family
doctor we went to an ER known for doing good work. The stitching took 20
minutes. The bill came up at $11,000 USD. Or $30K / hr.

That's nothing but greed. There is no reasonable explanation for that bill.

~~~
refurb
Calling it "greed" ignore the complexities of the US healthcare system.

Let me ask, was the claim for $11K or was the amount paid $11K?

~~~
gorbachev
Claim was $11K, insurance paid $11K, but only after trying to not pay for two
years and the doctor asking "nicely" for me to pay the whole thing.

------
krzyk
Wow, so the cheapest panoramic x-ray is $60 in USA. I paid for mine in Poland
34 PLN (which is slightly more than $9), some time ago.

And right now my dentist gets me those (and tomography when needed) included
in the treatment price (which doesn't change depending on the fact if I need
the scans).

BTW. Dentists services are almost completely private in Poland - I don't know
a single person that uses the dentists that are provided by the state (which
are cheaper or even free).

It is quite different for other health related professions.

------
pravula
Look at how much the insurance company actually pays for that $200 xray. It
may be comparable.

------
appleiigs
This is a classic economics 101 topic (Purchasing Power Parity). Prices should
equalize, but can't due to barriers such as customs and immigration laws.

Obligatory Big Mac index link: [http://www.economist.com/content/big-mac-
index](http://www.economist.com/content/big-mac-index)

------
arjunvpaul
How fitting that it took the longest article that TIME has ever published to
explain this. Here is a link [https://goo.gl/SAqq6F](https://goo.gl/SAqq6F)
(the original is behind a paywall).

If the only thing you learn is about the term "Chargemaster", then you are
half way there in understanding this scam. I personally think YC should have a
Call for Proposals just to disrupt the Chargemaster.

Journalist and author, Steven Brill won the Sidney award for this work
[https://goo.gl/StZXGA](https://goo.gl/StZXGA) . He also later wrote a book on
this called America's Bitter Pill: Money, Politics, Backroom Deals, and the
Fight to Fix Our Broken Healthcare System . Amazon link here
[https://goo.gl/r2yk6A](https://goo.gl/r2yk6A) .

------
nickbauman
Mostly for the same reason a Swedish bus driver gets paid 50x an equivalent
Indian one does. Protectionism. Most of the "free world" relies on this
practice of immigration control to keep wages high. You really _don 't_ want a
free market unless you're from a poor country.

~~~
nine_k
Immigration control is not _only_ about the job market.

------
arjie
Americans tie consultation to scans. The opinion on the scan is often done by
the same establishment that does the scan. But diagnosis is hard, and
operating a machine not as hard. America doesn't allow market principles to
handle operation because it's hard for an efficient market to apply in
diagnosis. Tying these two things together, with the additional weight of the
unwieldy insurance industry with its inefficient pricing means that everything
costs more. This is not to mention the fact that insurance's regulatory
capture is choking the industry.

Besides, Americans don't know how to run a market in health. It's a cultural
thing. They deify classes of people and then have trouble fitting them into
reality.

------
SilasX
This just goes back to the cost disease problem we observe in health care,
education, and housing in America.[1]

My takeaway from the discussion is that the big cost inflators are:

A) Litigation. Not that you can screw the customer without consequence
everywhere else, but it makes the same conflict much more expensive and
uncertain. In other countries, malpractice is handled by regulation, so suing
over anything _not_ covered by the regulators is virtually impossible.

B) Lack of transparency; no one knows how much something should cost, and why,
and what they're getting for the more expensive option, _and also have the
incentive_ to reduce it, so cruft can persist.

You might be tempted to explain the difference by labor costs, which are
higher in the US, but labor is also more productive in the US which should
mostly cancel it out. Plus, in India they probably have to pay more for the
equipment, which further mitigates the locality effect.

[1] HN discussion linking to SlateStarCodex article:
[https://news.ycombinator.com/item?id=13613687](https://news.ycombinator.com/item?id=13613687)

------
2close4comfort
The cost is inflated to what the insurance market will bear in the US, with no
market pressure like that in India and people paying for what they use you
have a much more realistic price.

------
benevol
Put very simply: It's a corrupt system.

And it's been know for a long time, so the only thing that's new is that some
people are becoming aware of the degree of corruption.

~~~
refurb
Corruption how? Just calling it corruption isn't really that helpful.

------
gumby
Not to defend the appalling US system but the costs of _operating_ a dentist's
office in the US is higher. There are environmental laws concerning the
chemicals used and disposal (if you drill into someone's legacy mercury
filling you have to dispose of the debris carefully for example), drug
handling and disposal, and of course malpractice insurance premiums.

All that being said, dentists in the US make out like bandits.

------
sigmaintegrale
Sorry for the broad reply but Supply and Demand; Cost of living. Plus we
assume that the service in India is the same as the USA. USA also has much
more overhead in running a company that India, which from what I understand is
still very much a cash oriented society.

------
readhn
Simple: it can cost up to $300,000 to become a dentist in USA. It probably
costs 100x less in India.

Before dentist charges for that first X-ray he or she is already potentially a
few hundred thousand dollars in debt...

Folks would charge a thousand dollars for X-Ray if they could get away with
it.

Welcome to capitalism.

~~~
manquer
To get a good dental degree with masters in india without govt scholarship? It
costs atleast 200-250 k USD . It is misconception that education is cheap here

~~~
readhn
this is news to me that in India tuition costs are more expensive than in some
public colleges in USA...

------
user-on1
So if there is a dental patient in America and if in case he can reach both a
dentist in America and a dentist in India in exactly 1 hour, would he choose
to go to dentist in India or dentist in America?

Costs are as in title.

------
exabrial
Just curious, what country was the machine developed in and originally
certified in? It seems a lot of medical stuff is developed American health
companies, certified by the FDA, then exported... Not the other way around.

~~~
spapin
Do you think pharma companies that develop this are going: "we will develop an
X-Ray machine, and only Americans will pay for it"?

I would assume they try to get a profit anywhere they sell it. Which means $20
x-ray is a realistic profitable cost per x-ray. But the US healthcare is so
broken that they manage to extract 10x more money out of it.

~~~
mitchellst
Actually... kind of.

Imagine you're a French pharma company. You know the US is the richest country
in the world and spends a quarter of its massive GDP on healthcare. When you
put together R&D budgets, it makes sense that you plan to recoup most of your
investment in the US, and that US FDA approval is one of your most important
goals.

Of course they want a profit anywhere they sell it. But the calculation would
change if the US health care system weren't so "messed up." You may not make
the investment at all, because you couldn't recoup it over a reasonable
timeline without the margins you get in the US.

The US rewards advanced medical tech development more than any other country.
There are many things wrong with our system, and this might be related to some
of them. But on its own, it belongs in the W column.

~~~
user-on1
> spends a quarter of its massive GDP on healthcare.

isn't most of it for wasteful reasons.

>There are many things wrong with our system

Many people are saying this often, seems like people have just surrendered and
submitted themselves to organized skillful abuse by such systems. Wish we have
more cumulative willpower than present.

------
Gurushek
Brain less topic, everything depends upon value of the money (other bla bla
things , cost of sources,workers salary etc). , example: 2 liter coca cola
-78rs , in us 2.40$ (more then 220rs)

~~~
kalleboo
Except there are many examples in this thread of other developed countries
with high material and labor costs but that can still offer affordable private
dental care.

2-3x the cost of India? Sure. 10x? Now it's starting to get out of wack.

------
abhishekgarg120
You should watch this.
[https://www.youtube.com/watch?v=CeDOQpfaUc8](https://www.youtube.com/watch?v=CeDOQpfaUc8)

------
mitola
If i remember it correctly i did it in central european country privately (not
public) for around 25 euros or something like that

~~~
mitola
Which is around 2 times more than in India.

------
jitendrac
That is not true, X-ray in india costs around INR 300 ($5)to INR 120($2) based
on the hospitals and trust managed orgs.

------
tryingagainbro
salaries.

rent.

assistants.

employees to deal with insurance crap.

INSURANCE--say, if you get mouth cancer 12 months later you'll sue them for
missing it.

most likely they paid 5-10 times more for the equipment, being USA and all.

~~~
user-on1
Sounds like we are paying so much money for a for a big lie.

------
starrychloe
Lack of competition

[https://www.youtube.com/watch?v=fFoXyFmmGBQ](https://www.youtube.com/watch?v=fFoXyFmmGBQ)

------
itamarst
1\. Labor costs.

2\. USA has insane health system where everything is more expensive than it
has to be because "freedom".

You can remove that 2nd factor by comparing costs with country that has a sane
socialized medicine/single payer system.

~~~
TkTech
To compare, in Canada where medical coverage is socialized but dentistry is
[usually] _not_ , the cost of a set of x-rays (2 or 4 shots) maxes out at
$100-$200 when uninsured.

~~~
ajeet_dhaliwal
I had 2 shots done last week in the UK, only £20, I think it’s partly
subsidised by NHS.

