
Why Medical Bills Are Killing Us (2013) [pdf] - ScottBurson
http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf
======
WalterBright
Here's an in-depth article explaining it:

[http://www.theatlantic.com/magazine/archive/2009/09/how-
amer...](http://www.theatlantic.com/magazine/archive/2009/09/how-american-
health-care-killed-my-father/307617/)

tl,dr: it's because people who incur the costs are not the people who pay for
it.

~~~
ScottBurson
That's a thoughtful piece, with some interesting suggestions toward the end.
Your "tl;dr" is not inaccurate, but I hope people will read the whole thing.

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mmel
If anyone is interested, you can look up what single payer costs[1] are for
various procedures in Australia, you _can_ pay more than what is listed if you
go private, but it still isn't anywhere near the cost of what procedures cost
in the USA.

[1]
[http://www.mbsonline.gov.au/internet/mbsonline/publishing.ns...](http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/45CBF3F97BA64FBDCA257FD5000E6666/$File/201607-MBS.pdf)

~~~
james0001
Can you get a private MRI without a doctor's requisition in Australia? I know
in Canada they try to burn you at the stake if you do that.

~~~
distances
Why would one get a private MRI without doctor's orders?

~~~
cardiffspaceman
Because you don't have claustrophobia and you're interested in what the MRI
might show.

~~~
nomel
Why should curiosity be covered? A similar scenario involving car insurance,
and curiosity of "what's inside", would surely be considered fraud.

~~~
james0001
It doesn't need to be covered just don't try to restrict me from diagnosing my
own health when doctors have shown their shit at diagnostics

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no_protocol
Why did the patient in the first story absolutely need to travel from Ohio to
Texas for treatment? Isn't medical knowledge shared between providers?

Some of the blame in many of these situations should fall upon the patients
for choosing the care they did. Especially when it is a planned operation. I
haven't finished reading the whole article, but so far it doesn't seem to be
considering this point. I don't wish to defend the existing system in any way,
but these providers just seem to be giving people what they ask for.

~~~
rch
I used to work at M.D. Anderson and I can attest to their quality of care.
People travel from around the world to receive treatment, for good reason.

Also, my mother was a patient there. She started treatment just a couple of
months after I got my job actually. She's still doing well years later, and is
glad she waited an extra month to get into M.D Anderson. The decision to wait
was excruciating though.

~~~
no_protocol
You seem to have some firsthand knowledge of the situation, maybe you can help
me with the question I posed earlier.

This medical center in Texas seems to be providing a great level of service. I
am wondering why patients need to attend directly to get this level of care. I
thought that medical findings were published in journals and shared among
professionals in the field.

If M.D. Anderson has a dozen (or a hundred) doctors that are experienced in
the treatment of certain diseases, why aren't they sending half of those
doctors out to other parts of the world to spread that knowledge?

~~~
ihodes
Your questions are very good, and I answer them below briefly in the interest
of expediency, not to be rude.

1\. Some knowledge is shared in journals; most knowledge isn't published until
years after it's established. Much is never published, and is learned through
word of math, and institutionally encoded. MD Anderson is world-renowned for
being a center for excellence in cancer care.

2\. Doctors don't read every article published in every journal related to
their work. Even if they did, or read much of it, synthesizing into practice
is a very different (and difficult) matter. Many of them don't read at all.

3\. Why would MDs want to be send worldwide? And why would MD Anderson want to
send them all over? Who pays for this? How can a doctor affect change in a
large hospital system?

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FussyZeus
Speaking as an extremely pro-Capitalist person, this is the kind of area where
Government interventions are required. Capitalism and fair markets require a
few basic things:

\- Informed consumers (most consumers of healthcare either don't know enough
about it to make any solid judgement) \- Competition (most hospitals in any
given area are grouped together and rarely compete, if at all) \- Choice (if
you're in an ambulance, you can't exactly instruct the EMTs to take you to
'the better hospital'), plus when it comes to niche treatments like chemo,
there often aren't any choices, just the closest one to you that offers the
service you need.

And again as a Capitalist: You take a high value, required product, mix with a
group of consumers who don't have a choice whether or not to buy, and a
business minded person with no ethical compass whatsoever and you'll have
record profits and screwed customers. Simple as that.

~~~
yummyfajitas
As a person who consumes capitalist medicine in India, I don't see how any of
your issues are fundamental to capitalist medicine.

There is plenty of competition among hospitals. You can choose which one to go
to (from an ambulance or any other time). Customers are strongly price
sensitive and prone to comparison. There are plenty of choices as to where to
go.

Assuming I'm well enough to travel, I'll always fly to capitalist India to
have my medical work done.

 _And again as a Capitalist: You take a high value, required product, mix with
a group of consumers who don 't have a choice whether or not to buy, and a
business minded person with no ethical compass whatsoever and you'll have
record profits and screwed customers. Simple as that._

So do you believe that Indian doctors/other medical types are just vastly more
ethical than the (very often Indian) doctors in the US?

~~~
FussyZeus
I can't comment on India's medical system, never used it and never really
researched it. However:

> You can choose which one to go to (from an ambulance or any other time).

In theory, yes, in practice, it's a little harder. I mean if you were just in
a car crash it's not a guaranteed thing that you're going to be capable of
speech, let alone coherent enough to make your choice. And more importantly
you shouldn't have to, your concern at that moment should be "put my head back
together please" not "is this lifesaving treatment going to cost me my home."

> So do you believe that Indian doctors/other medical types are just vastly
> more ethical than the (very often Indian) doctors in the US?

This is not American doctors doing this (or at least, not the topic of this
article): This is American businessmen who have no background in medicine that
are making these decisions.

~~~
yummyfajitas
_I mean if you were just in a car crash..._

So in that case, lets have $YOUR_FAVORITE_SYSTEM for emergency medicine and
capitalism for the rest. The vast majority of medicine consumed is not
consumed in an emergency situation.

 _This is not American doctors doing this (or at least, not the topic of this
article): This is American businessmen who have no background in medicine that
are making these decisions._

So are Indian businessmen with no background in medicine more ethical?

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peter303
The examples in the article are before ACA. Both prices and insurance
availability have changed since then.

~~~
theandrewbailey
No doubt, prices have gone up even more.

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ScottBurson
I came across this last night and stayed up too late reading it. It's a
fascinating exposé of where at least a good part of the money is going -- the
extra money that we Americans spend on health care that doesn't bring us any
better outcomes.

I think it's relevant to HN because a lot of us with families and/or in middle
age can't risk quitting our jobs to start startups without assurance that
we'll be able to buy adequate health insurance at a price we can afford -- and
every dollar counts in a startup. I know I've seen people post here that
Obamacare was an enabling factor for them, and it's now obviously at risk. So
the policy discussion about what it should be replaced with is very relevant
to us.

This piece, along with others I've read recently, suggests to me the following
overview of the problem:

() The market for health care services is highly distorted. Not only is there
no price transparency, but patients don't even have the authority to make
purchase decisions on their own behalf -- that's done for them by the doctors.
To the extent patients have any say in the matter, they are unlikely to be in
an emotional state conducive to hard-nosed negotiating, if there is any
urgency to the matter at all.

() Multiple special interest groups have gotten themselves politically
entrenched. The service providers may be the most successful of these, but
there are also the insurance companies and the malpractice lawyers. The amount
of money flowing through the system supports armies of lobbyists, who have
compromised legislators of both parties.

() _There are no easy solutions here, no free lunches. You can’t have all the
good parts of an unregulated insurance market (freedom to buy what you want,
when you want, with market pricing) without the bad parts (steadily rising
premiums and insurance that is unaffordable for people who are old and sick).
At the same time, you can’t have all the good parts of a socialized system
(universal coverage at affordable prices) without freedom-reducing mandates
and regulations and large doses of subsidies from some people to other
people._ [0]

So, HNers, what's the solution? Would love to hear people's thoughts.

Personally I can't resist fantasizing that Trump will come to the same
conclusion I have: single payer is the only solution. It would be like Nixon
going to China. Trump (whose election I vigorously opposed) is unencumbered by
considerations of who donates how much to which Congressional campaigns. And
for all his flaws, he's a hell of a salesman. If he gets it into his head that
this is the solution, it could really happen.

A pipe dream, I know. But would you like to see it? If not, what do you think
would be better?

[0]
[https://www.washingtonpost.com/news/wonk/wp/2016/11/12/donal...](https://www.washingtonpost.com/news/wonk/wp/2016/11/12/donald-
trump-is-beginning-to-face-a-rude-awakening-over-obamacare/)

~~~
ams6110
Routine medical care should be like food and shelter: something you are
expected to pay for yourself. That would put price pressure on providers.
Insurance should be a backstop for catastrophic accident or illness. It should
be sold by competing local and national providers. It should be untangled from
employment as a benefit. You should buy it like car insurance.

Obama, Trump, Clinton. senators, representatives -- none (or very few) of
these people have any medical background and really can do little else but
screw it up as badly as if the government was the single provider of all
software.

~~~
nradov
Maybe it _should_ be that way, however in practice it doesn't work. The ACA
specifically requires free preventive services because research has shown that
when patients have to pay they often skip it. And when they skip preventive
care that causes the spread of infectious diseases, and allows small problems
to turn into serious problems that are more difficult and expensive to treat.
So this is important from a public health standpoint regardless of concerns
over economic efficiency or personal responsibility.

[https://www.healthcare.gov/coverage/preventive-care-
benefits...](https://www.healthcare.gov/coverage/preventive-care-benefits/)

~~~
coredog64
Preventative care that actually works is super cheap and not controversial
(mostly vaccinations). This idea that we can save vast sums via preventative
care is a fantasy. You may find anecdotes to support it, but the serious
literature doesn't bear it out.

~~~
ceejayoz
> Preventative care that actually works is super cheap

The same's true about car maintenance, but plenty of people drive on dying
brake pads and stretch oil changes anyways. A hundred bucks for a checkup is
still more than many folks are willing to pay. As an example, here's a kid who
died for want of a $80 dental procedure: [http://www.washingtonpost.com/wp-
dyn/content/article/2007/02...](http://www.washingtonpost.com/wp-
dyn/content/article/2007/02/27/AR2007022702116.html)

> not controversial (mostly vaccinations)

LOL.

~~~
cableshaft
Well they usually want to do more expensive procedures along with the dental
extraction. I've been delaying mine a bit because they want to take it out
then put in a bridge, which will cost $1800 (normally $6700, but I have good
dental insurance). In fact the extraction will be free, the cost is all in the
bridge. But now you've got me paranoid again. Damn.

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joggery
Check out healthcare costs by age:

[http://blogs-
images.forbes.com/danmunro/files/2014/04/hccost...](http://blogs-
images.forbes.com/danmunro/files/2014/04/hccostsbyage.png)

Hence the importance of research into life extension technology combined with
provision of assisted suicide for those who wish to die.

~~~
maxerickson
That's spending though right?

Part of what the article is saying is that spending isn't a great proxy for
cost.

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nradov
These debates about insurance and payment models are important, but still
ignore the biggest issue. US healthcare expenses increasingly go to treating
conditions caused by poor lifestyle choices: obesity, substance abuse, and
sedentary lifestyles. Certainly there are ways to cut waste and shift costs
around more equitably but unless we can improve those root cause factors we're
only going to be kicking the can down the road. At some point we just won't be
able to provide effective care to everyone regardless of who's paying or how
much providers cut prices.

Even countries with socialized medicine are going to run into the same issue.
Canada and the UK are only slightly better off in those lifestyle choice
factors than the US, and their trends are moving in the wrong direction.

~~~
orangecat
The root cause is aging. You can exercise religiously and never touch sugar,
and at best that will result in racking up huge medical bills in your eighties
rather than your sixties.

~~~
voxic11
Also if you die in your 80s you will have collected way more social security
money then if you die in your 60s. I wouldn't be surprised if things like
smoking which tend to kill you right before retirement age actually saves us
money as a society.

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Retric
I think MRI's are a great example of the costs.

An MRI machine used on average 10 times a day for 10 years can do 36,500 scans
at the cost of ~3 million for the machine. 3,000,000 / 36500 ~= 82$ for the
machines time. (Clearly more if it's used less often, but also clearly not
500+$.)

This is a case where the actual cost has almost nothing to do with the machine
it's all about manpower + some consumables. So, what's the manpower actually
doing? A huge chunk of time in the US is simply billing aka waste.

~~~
gbrs
Does that $3 million also include the expertise needed to operate and maintain
the machine? You also need to account for the money the hospital needs to save
to buy a new one when the one they have becomes outdated. Still might not add
up to the actual cost they charge for a scan but it would look a bit more
reasonable. My guess is the different negotiated rates for insurance plus the
low income policies make everything convoluted and add a decent amount of
overhead. I wish they would stop this negotiating crap and charge whatever it
costs for them to do a scan. At least then I will know how much it will cost
upfront.

~~~
maxerickson
It's perhaps more stark with the CT scanners mentioned in the article.

They pay off the capital cost in 1 year. If you figure they need two imaging
technicians on site 24 hours a day, the labor to staff the machine is roughly
6 * $200,000, or $1.2 million per year. If they average 1 scan per hour (a
scan can take as little as 5 minutes), the labor cost of those techs is $140
per scan.

If it costs more than $1 million dollars to service the machine per year (the
machines cost less than that new), the service cost is $140 per scan.

Hospitals routinely charge $2000+ for CT scans.

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ainiriand
It is good to live in a country where I only spend 50 euro per month in taxes
for all the care I could need! Its great to be in the first world!

~~~
finid
What's the country?

~~~
awesomerobot
Most of Europe

~~~
Freak_NL
Monthly rates vary though. In the Netherlands you pay €90 or so a month for
(mandatory) health insurance, with a €350 a year deductible. Low income
households do get partly subsidized by the government of course.

~~~
_pr
The Netherlands spends ~$5200/pp on healthcare[1]. Where does the rest of the
money come from?

[1]:
[http://www.who.int/countries/nld/en/](http://www.who.int/countries/nld/en/)

~~~
Freak_NL
Taxes withheld from salary, just like ainiriand mentioned. In The Netherlands
(and most other European countries) you pay for insurance directly (which here
includes a mandatory basic plan that can be expanded to include things like
full dental) and via taxation of income.

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clifanatic
That link was confusing - I was expecting some research from UTA (The
University of Texas at Arlington), but apparently it's an article from Time
magazine that a UTA professor published on his personal web site.

