
Why an MRI costs $1,080 in America and $280 in France - Flemlord
http://www.washingtonpost.com/blogs/ezra-klein/post/why-an-mri-costs-1080-in-america-and-280-in-france/2011/08/25/gIQAVHztoR_blog.html
======
tzs
What annoys me as an American about our health care is not that some other
countries achieve better outcomes at much lower cost--it is that they do so in
so many different ways.

For instance, if they all did it by having the government completely run the
health care system, with all doctors working for government hospitals and
clinics, and being trained in government medical schools, with all costs set
by the government, then I could understand the US rejecting that as being too
much government intrusion. (Note I didn't say I'd necessarily agree with such
rejection--good health care arguably is more important than limited government
power--I'm just saying I could understand such rejection).

But looking around, what stands out is how diverse the approaches of other
countries are. There are some that do have the government finance and provide
health care, much the way the police or military are provided by the
government.

There are some that use private insurers paying, with care provided by private
hospitals and doctors, but the insurance companies are non-profit and
regulated.

There are some that provide care via private hospitals and doctors, but have a
government run insurance program to pay for it.

There was a good look at how it is done in 5 capitalist democracies here:
[http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/c...](http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/)

See also the link on that page to the explanation of the four basic models
used around the world. That page includes a striking way to explain the other
systems to Americans:

    
    
       These four models should be fairly easy for Americans to
       understand because we have elements of all of them in our
       fragmented national health care apparatus. When it comes
       to treating veterans, we're Britain or Cuba. For Americans
       over the age of 65 on Medicare, we're Canada. For working
       Americans who get insurance on the job, we're Germany.
    
       For the 15 percent of the population who have no health
       insurance, the United States is Cambodia or Burkina Faso
       or rural India, with access to a doctor available if you
       can pay the bill out-of-pocket at the time of treatment
       or if you're sick enough to be admitted to the emergency
       ward at the public hospital.

~~~
iwwr
Don't forget that in Canada it's illegal to be a private medic. Medical
services are ostensibly free, but rationed through queues. If you have a
medical condition that's not immediately threatening, you may find yourself
waiting for years for treatment, or have to go across the border to buy it.

~~~
_delirium
That's not a requirement of such a system, though; France has a dual
public/private system, where everyone is guaranteed service at the public
system, but well-off people who wish to pay extra can purchase private care.

~~~
DanBC
That's true of the UK system too. People get public treatment, but can go
private if they wish. There are some restrictions on novel cancer medications
if those are shown to be both expensive and minimally effective. I don't know
if it's a good thing that dying people are protected from high pressure
selling of pharmaceutical companies or whether the government should just
allow people to spend tens of thousands of pounds on medication that may not
extend their life and may not improve (and may decrease) their quality of life
for the remaining weeks they have.

------
droithomme
The US has inexpensive MRIs as well.

This nationwide chain provides MRIs as low as $335 depending on the state.

<http://a2zimaging.com/>

No insurance accepted, no payment plans. Those cost money. Just charges the
cost.

~~~
anateus
Similarly MedLion (<http://www.medlion.com/>) provides primary care in Santa
Cruz and Silicon Valley for $59/mo + $10 visit in part by not accepting
insurance (they claim on their website it saves them 40% in costs).

Insurance works great for catastrophic things, just like car insurance and
then it clearly makes sense to make it universal. If you could only buy gas
through your car insurance--who occasionally would decide you drive too much
and not cover this months' gas--you can bet prices would go sky high.

~~~
danmaz74
I'm all in favor of universal health care, but having universal (private)
insurance without a collective bargaining system raises a lot of problems. For
example, here in Italy car insurance is mandatory, but people choose where to
make their car repairs, and prices aren't regulated in any way. The results:
Once I went for a repair, and got quoted something like 150€ - I told the
repairman I thought I was covered by my insurance. Then I discovered that
particular problem wasn't covered, and well - the prices magically came down
to 70€ "You know sir, with insurances we have all those additional costs...".

~~~
matwood
_"You know sir, with insurances we have all those additional costs..."._

Well, with many insurance companies there _can_ be an additional cost.
Submitting the claims, filling out the paperwork, proving the work was done,
etc... all add up. Depending on how much work a person does with an insurance
company it could easily add up to another full time employee.

~~~
danmaz74
I believe that there are _some_ additional costs. But come on, more than
double the price... ;)

~~~
estel
Depending on the hourly rate, €80 of paperwork isn't all that much.

~~~
danmaz74
Ok, probably the absolute value of the (very simple) repair doesn't make this
a very significant example. But for sure it was a pretty big overhead.

------
mindcrime
Can't believe they didn't even mention the Monopoly Protection Certificate
racket run by the government in many states:

<http://en.wikipedia.org/wiki/Certificate_of_need>

And never mind the huge monopoly granted to AMA certified physicians, in terms
of providing medical care. Of course those guys have a huge incentive to keep
as many people out of the physician pool as possible. We certainly couldn't
allow competition, which might drive down costs. :~(

~~~
prostoalex
The labor costs would vary from country to country. The article questions the
price of a service performed by machine (that supposedly differs very little
from country to country).

~~~
hudibras
So why doesn't the U.S. allow doctors to immigrate to this country? The median
American MD makes $143K; I'm sure that plenty of foreign doctors would love to
come here and make half that.

~~~
prostoalex
There's no specific provision disallowing immigration of doctors. For obvious
reasons it's an occupation that requires licensing/certification, which is
more cumbersome than many are willing to consider, and reasonable English,
which is usually not a priority in medical schools around the world.

------
cpeterso
Not only do Americans spend more per-capita on health care than Canadians, the
_American government_ spends more per-capita on health care than the Canadian
government. And yet Americans _still_ need private medical insurance. And
depending on how you count, more than 60% of American bankruptcies are for
unpaid medical bills and about 78% of those people _had_ medical insurance.

[https://en.wikipedia.org/wiki/Comparison_of_the_health_care_...](https://en.wikipedia.org/wiki/Comparison_of_the_health_care_systems_in_Canada_and_the_United_States)

~~~
jasonlotito
Having lived in Canada for 10 years, and recently moved back to the US
_because_ of health care, I can attest that while Canadian health care looks
good on paper, it's not. Sure, it's there when you need immediate emergency
care. But for anything long term, it's horrendous. Autism, for example, is a
perfect example, and something I know first hand. In Quebec? The best thing
you can do for autistic children is to leave and get out of there. My wife, a
Canadian, was afraid when she first heard about US healthcare, but when she
finally got to experience first hand the full brunt of the system, she
despised it. We had more help for my son in the first 2 weeks of being in the
US then he'd had in more than year fighting for it in Canada.

To top this all off, Canada still has private insurance, and while you don't
_need_ it, if you don't have it, it makes for much lower quality of care (and
don't think the public option covers essentials, either).

So, no. I could never put my sons through a system like that again. It was
down right abuse, and I don't use that word lightly.

~~~
jaems33
Different strokes.

Having lived in both countries, my experience in the U.S. was less than ideal.
About the same amount of wait times as in Canada, and the doctors I saw gave
me very little options as to how I could treat one of my chronic injuries.
Never suggested a follow up appointment, physio, or even x-rays/MRI's to get a
better look. In Canada, they recommended me a specialist, and I have a nurse
at a clinic who has built a great relationship with me to assess my needs when
I need help, as well as x-rays/MRI's done within a week.

My experience isn't like all in Canada or the U.S. but after touting how much
better I thought the U.S. would be because of my great insurance and living in
one of the top cities in the country, I wasn't impressed at all.

~~~
jasonlotito
Different strokes? Yeah, that doesn't mean what you think it means.

Regardless, it's great that you have a happy story to tell. It's mostly
meaningless. The original point is, Canada's system isn't better. It's just
another system, with it's own problems. I mean, do you really think your story
will change the facts of mine? Does it matter? No.

And, to top this all off, you try to equate "not being impressed" with abuse?
Really?

------
jostmey
I once had to have a CAT scan done. I was really scared. I asked how much it
would cost. No one was able to tell me! I was told the price would be
negotiated with my health-care provider, if they opted to cover the procedure.

How can there be competition when no-one can give you the price of the
procedure? Seriously WTF.

~~~
Cadsby
This is because no one is quite sure what it should cost. Literally. The
hospital will try and charge whatever wild number they can get away with, and
the insurance company will negotiate it down to whatever they feel they're
willing to pay.

My wife is a nurse and has seen this play out multiple times with patients and
their families. Just to give you an idea of how disconnected the price is from
logical factors, consider this - If the hospital bills the insurance company
they might charge $1000 for the scan. If they bill you directly, (always after
you've had the procedure of course), you will be charge much much more, say
$3000.

Why? Because it's next to impossible for you as an individual impossible to
negotiate the price before hand. (How would you know what a fair price is? And
are you really go to say no to a procedure that might be critical for your
health?)

~~~
underwater
People argue that the current system works because capitalism is more
efficient. But when the prices are hidden from the customer by either fudging
prices or hiding costs behind a fixed fee in the form of insurance the system
is broken.

~~~
rsynnott
This seems to be one of the fundamental misunderstandings people have about
capitalism; they like to think of it as a form of virtuous economic freedom. A
market system, however, only works with reasonable information. In this case,
it is apparently of benefit to the providers to treat them as trade secrets,
but the system will operate more efficiently if they are forced not to do so
(as they are in most places).

------
asmithmd1
High health care spending is yet another way the US subsidizes other
countries. From the article:

"This is a good deal for residents of other countries, as our high spending
makes medical innovations more profitable. “We end up with the benefits of
your investment,” Sackville says. “You’re subsidizing the rest of the world by
doing the front-end research.”

In the past 30 years have you heard of any medical innovation or drugs coming
from anywhere other than the US?

Of course the MRI machine was itself invented in the US:
<http://web.mit.edu/invent/a-winners/a-damadian.html>

~~~
illumen
"In the past 30 years have you heard of any medical innovation or drugs coming
from anywhere other than the US?"

Of course there is plenty of good medical stuff coming from many countries
other than the USA. The market for medical care world wide is way larger
outside the USA too. Finally, much medical research is multi national and
collaborative.

~~~
jandrewrogers
A fact I find distressing is that the poster is largely correct. Somewhere
around 70% of biomedical R&D is done in the US, the utter dominance of the US
in this market is not controversial. Most of the rest is done in Asia. The
biomedical R&D done in Europe is rapidly approaching a rounding error. I, for
one, do not like the fact that the entire world is dependent on the biomedical
R&D of US companies. Yet that is the current state of affairs. And the private
companies in the US spend money on this research that dwarfs what all but a
few countries spend.

I wish more people would acknowledge this reality. I like biomedical
technology advancement. Most of it is developed in the US because it is the
one of the few countries that can absorb the cost of the R&D. If the US stops
doing it, who is going to pick it up? There is ample evidence that the answer
is "a little bit in Asia and nowhere else". That should be frightening to
people. Biomedical R&D is important.

Ignore for the moment that the US healthcare system is a wreck. The fact
remains that the majority of biomedical advances come out of the US because it
is the only country where people absorb the R&D cost. If Europe was pulling
its weight with biomedical R&D it would be one thing but in practice it is
producing so little in that regard that it is kind of shameful. If we
eliminate US biomedical R&D by eliminating their ability to recover costs, who
picks up the slack? There are no easy answers.

~~~
illumen
Bullshit. Show me where you get this 70% figure from? Are you talking about
spending or results? I think you pulled it out of your arse, but would love to
know. What I found was, European r&d spending is close to what the USA spends.
Individual countries spend more as a percentage of GDP than USA. World wide,
USA does not appear to be spending anywhere close to 70% of the total on
medical r&d.

* 2011 Nobel prize for medicine went to an international crew (2 from europe, 1 USA)

* 2010 Nobel prize for medicine went to a British man.

* 2009 2 women from the USA, and one man from UK.

* 2008 1 german man, 1 french woman, 1 french man.

Anyway, medical care isn't just about what drugs multi national companies
produce (with much funding from Asia and actual research done in Asia and
sales done in USA+worldwide). It includes things like reducing obesity,
stopping people smoking in bars, and providing good medical care for all
people - which reduces sickness spreading. It does take research, and
development to figure these things out and implement them on a social level
successfully. Many of these things are classed as social science, and not
included in R&D in many places. They can't even get R&D funding for this stuff
in some places because it is not real science apparently.

Tax credits for r&d also distort the real costs. The UK gives 225% r&d tax
credits, and Australia gives 175% tax credits of the cost now(USA has them
too, but lower). This means you make money purely from just doing the R&D
without worrying about the results.

btw, the USA is massively in debt, and over 22% of US companies being foreign
controlled. So even if the US companies were contributing that much R&D,
shouldn't that proportion be attributed somewhat to other countries? With all
the funding into the USA also coming from other countries, shouldn't some of
that be counted towards the other countries? Shouldn't the fact that lots of
the workers in R&D labs for US companies have been outsourced to other
countries count towards those countries?

~~~
rsheridan6
The Nobel Prize is for basic research. Once you've done the basic research,
you're still looking at spending huge amounts of money, on the order of a
billion dollars, and spending 15 years bringing it to market. The drug
industry is in trouble even as it is, and obviously they would be in worse
trouble if they had to sell as cheaply in the US as they do in the rest of the
world.

>So even if the US companies were contributing that much R&D, shouldn't that
proportion be attributed somewhat to other countries?

No, at least not for that reason. The important thing is not where the
innovator is located, but what market they target.

------
apinstein
The article completely ignores structural problems that lead to high prices.
Since the US health care market effectively has government price controls (due
to Medicare, which is a huge percentage of revenue for most facilities), this
causes some perturbations in the market.

Pretend you're an optometrist. Historically you got paid well for your time,
so you organized your business around seeing as many patients as possible and
referring out things like labwork, glasses-making, etc, since you couldn't
compete on price with shops that kept their capital equipment busy nearly
24/7. Life is good; you get paid well for your time and your customers get
reasonable prices on things like labwork, glasses, etc.

Over time, your medicare rates keep dropping. Eventually you actually start
losing money when you see medicare patients. You then realize that the
labwork/glasses part of the business is pretty high margin, and even if you
buy a machine and keep it barely busy, you can still eek out some profit from
keeping that work in-house. So you buy some equipment, and instead of
referring out labwork and glasses, you start doing it in-house. Again you can
finally make money on medicare patients.

The medical device companies LOVE this. What better way to expand your market
than "invest" (ahem lobby) so that your customers can make money with machines
that are only busy 30-50% of the time. That's 2-3x as many devices as if they
had 95% utilization, WIN! The doctors won't complain, b/c the system is so
messed up that they know it's the only way for them to actually make money.
And the insurers can't really do much about it b/c they can't force their
patients to go to a different facility as that's too intrusive.

So it's kind of a combination of market failure, lobbying, and price-fixing
that causes procedures to be way too expensive in the US since the normal
market mechanisms that cause prices to approach a small margin over the cost
at high capital utilizations to fail.

There's a lot more to it than that, but whenever I talk to my many relatives
in the medical industry, this is always happening, and it's a major factor in
prices. MRI machines aren't cheap (think $1M).

------
aculver
For what it's worth, it's ~$160 in Japan.
([http://www.npr.org/templates/story/story.php?storyId=1205455...](http://www.npr.org/templates/story/story.php?storyId=120545569))

Interesting seeing this here on HN after my wife and I just finished watching
"Frontline: Sick in America" on Netflix tonight, in which an American reporter
travels to 5 countries that provide some form of universal healthcare to
discuss (with doctors, administrators, and patients) the different mechanics,
what percentage of GDP they spend on healthcare, what wait times and gate
keeper policies are like, what financial issues exist, etc. The fixed,
negotiated price for MRIs was one of the things he discusses.
([http://movies.netflix.com/WiMovie/Frontline_Sick_Around_the_...](http://movies.netflix.com/WiMovie/Frontline_Sick_Around_the_World/70098734?trkid=2361637))
I grew up with nationalized healthcare, but found the documentary quite
informative.

~~~
rdl
MRI specifically is overused and kind of crappy in Japan. In the rest of the
world, the standard is for a 1-3T MR study; in Japan, you get a lot of 0.5 and
even lower (0.2T! wtf) MR studies. They're used for a lot of health
screenings, whereas in the rest of the world they're more often used for
actual problems.

~~~
veidr
I call bullshit on your first point--that MRIs are "overused" in Japan.

MRIs aren't something that can really be overused. Unlike CT scans, or pretty
much any non-MRI method of imaging the inside of the body, they don't harm the
patient.

Even though you are right that many of the MRI machines in Japan are lower-
resolution cheaper models, that is largely because there are way more MRI
machines here, and they are used for routine diagnostics, to _find_ actual
problems. Your local single-doctor clinic in the boonies often has mRI
equipment here.

I have a personal interest in this topic, as I have MS. Lucky for me, I am
doing fine, but in Japan I get a brain MRI every 6 months just to keep an eye
on how it is going. When I was back in the states 3 years ago I had a typical
employer-based HMO. I went to the doctor and told him here's my deal, I have
MS, my doctor in Japan said I should have another MRI in October to see what's
up with it.

The doctor flatly refused -- MRIs were only available after physical symptoms
had developed. Of course, at that point, the available treatments for a flare-
up of MS are less effective at preventing long-term neurological problems.
(Happily, I am back in Japan now.)

My point is that MRIs are a wonderful tool, and as you and other commenters
have pointed out, they are much more widely used here than in the US.
Something wonky with your knee? OK, let's get an MRI and check it out. I don't
see anything wrong with that.

And in cases where there _is_ a problem, there is no difficulty at all here in
getting a referral to a specialist at a hospital with the latest cutting-edge
MRI gear if necessary.

Using MRI technology for health screening and preventative/proactive treatment
is great.

~~~
rdl
All the rads I've talked to/worked with hate "screening" MR (or CT! Some
morons do CTs for random checkups!) not so much for the cost of the procedure
(since they directly or indirectly were getting paid), but because it leads to
finding basically insignificant incidental findings which then cause the
patient to worry, and/or have unnecessary surgery. The benefits are
questionable if anything, but the costs of the unnecessary surgery are high.

A needs-based study based on having MS, sure, but just getting an MRI as part
of a routine checkup, probably not.

~~~
phren0logy
Exactly this. Unnecessary imaging needs to unnecessary follow-up evaluations
like biopsies which in turn have additional complications.

When I was in med school we spent a lot of time in a hospital providing
indigent care. We ordered tests that we needed to determine how to treat
someone, but not more than that. When I worked in a private hospital, most
patients got lab tests done daily, with no specific reason for ordering them.

~~~
rdl
I'd be willing to buy that imaging is sometimes underused with some patient
populations, and sometimes overused -- just like medications, even
painkillers, which are dramatically overprescribed in some places (old people,
Florida, pill mills for diversion) and underprescribed for others (some
chronic pain patients, terminal care).

------
nhebb
The problem with studies like this is that they pick a single issue within
healthcare and try to make a broad assessment from it. There have been other
studies that break down the overall costs of health car in the US that are
more informative. It's four years old, but this McKinsey study is a good
example:
[http://www.mckinsey.com/Insights/MGI/Research/Americas/Accou...](http://www.mckinsey.com/Insights/MGI/Research/Americas/Accounting_for_the_cost_of_US_health_care)

The Interactive Flash slide show is interesting as well (where "interactive"
is defined as clicking forward and back buttons, I guess).

------
18pfsmt
Without yet reading any of the other comments, I have an anecdote that may be
interesting to others: One of my father's business partners has a mother that
lives in France. She is ~88 years old, and the family's net-worth is on the
order of 100s of millions ($USD). She had a medical condition which required
surgery, but due to her age, she was not eligible in France, so she had to
come to the US for her surgery. So, it seems like the phrase, "The US has the
best healthcare money can buy" still stands.

[I will now read the other 80 comments...]

~~~
nooop
> but due to her age, she was not eligible in France

I call bullshit on that. Due to general condition maybe, but if you are in
great shape except on one risky point and the risk of treatment seems
acceptable you are not going to be refused treatment because you are too old.

~~~
18pfsmt
Well, she was. She was deemed too old to receive the organ transplant, and the
fact that she was willing to pay extra didn't matter. She is now 95.

------
niels_olson
Just a plug for Paul Starr's The Social Transformation of American Medicine.
It's the definitive text on healthcare in America. After that, all the other
writing is quaint.

On a separate note, you should have seen the fear on the faces of the retired
English couple I saw today when I sent the poor man to the ER. They're here on
vacation, he had an MI 15 years ago, ran out of his aspirin a month ago on
vacation, now he has had vertigo for a week (stumbling like a drink) and new
onset high blood pressure. Never paid a dime for healthcare and I just sent
them to the lion's den. I reimbursed them the cost of my office visit, but
that will be a drop in the bucket.

------
InclinedPlane
US: 91.2 MRI scans per year per 1,000 population

France: 21.8 MRI scans per year per 1,000 population

~~~
Aloisius
Shouldn't that make the cost in the US go down? After your fixed investment,
the only thing you are paying for is the person running the machine.

~~~
true_religion
Not necessarily, if the person running the machine or the person screening the
results has to be a trained medical professional. In those cases, due to
monopoly and other concerns, we'd have a supply bottleneck which would
increase price given increased demands.

I don't however know if you have to be medically trained to use a MRI machine,
or interpret the results

~~~
foogoo1
One obviously has to be trained to use the MRI machine, and that person is
local. But the interpretation is even now not done on site.

Low bandwidth costs mean that it can be done halfway around the world.

------
knieveltech
How does this come as a suprise? We're paying to support the margins of for-
profit industries, including multiple tiers of middle-men.

------
ck2
Because if it was $280 in America the insurance ceos, investors, doctors and
administrators would not be able to buy their second vacation homes.

As long as healthcare is a profit center, you will only have the right to die
quietly if you cannot afford it in America.

~~~
shingen
It's a profit center whether you like it or not, with or without the
government. With the government the profit goes into the bureaucracy.

The medicare + medicaid system has shown itself to be an extreme profit center
for government employees and the bureaucracy. They take home massive sums in
profit: wages and pensions.

The government doesn't make the system more efficient by reducing profit from
the equation. They reduce cost by reducing care options, reducing salaries for
healthcare workers, and rationing. For example, nurses in America make 50%
more than nurses in Germany. Socialized medicine will decimate that pay
variance.

<http://www.worldsalaries.org/professionalnurse.shtml>

There's nothing on earth more wasteful than government when it comes to
spending money. Just ask the US government system (fed+state+local), it's a $7
trillion per year profit system, that flows directly into the hands of
millions of employees that make on average $100k per year in wages + benefits,
with that pay package doubling in size in just the last ten years, while the
economy flat lined.

~~~
njs12345
How do you explain the low costs and relative success internationally of the
NHS (in the UK)?

I've no problem with a free market approach to healthcare when it works. But
it seems hypocritical to criticise our approach for involving too much
government intervention (something which supposedly reduces efficiency) as not
being suitable for the US when it's more efficient than the current US system.

------
jksmith
I just got my shoulder redone by arguably one of the best sports orthos in the
country. This guy handles a substantial percentage of high profile
professional athlete cases per year. He charged me $3200 for a rotator repair
and bicep reattach. I think that's a bargain for his skill level.

My guess is the total bill will be another story though. I suspect my
insurance will be dinged for about $11k. O.R. rental, nurse anesthetists who
make $150/hr, etc are the source of expensive healthcare in the US, at least
for surgery.

------
ramblerman
" If we had the per-person costs of any of those countries, America’s deficits
would vanish. Workers would have much more money in their pockets. Our economy
would grow more quickly, as our exports would be more competitive."

Also world peace would break out and poverty would be eliminated.

I liked the article, and I think this is most certainly a pressing problem for
this country. But the facts are strong enough to independently make a strong
case. No need for the hyperbole

------
DanBC
With an increasing elderly population there's a need for a lot more care,
especially for people with dementias.

Here's one fascinating article about US prisons which face a serious problem.
(Caution: contains descriptions of violent crimes.)

([http://www.nytimes.com/2012/02/26/health/dealing-with-
dement...](http://www.nytimes.com/2012/02/26/health/dealing-with-dementia-
among-aging-criminals.html?hp=&pagewanted=all))

This shows that big improvements in quality of life can be achieved with small
changes. Give health care assistants better training about dementia and give
them more time to talk to patients. This small cheap change has several
benefits: nurses can do more nursing; meals get eaten; falls are reduced;
people feel like they're getting better care; etc.

------
jenhsun
Here is Taiwan's: PET(full body): 1500 USD, CT(head/partial): 200 USD,
MRI(head/partial): 670 USD

------
darksaga
"The question, of course, is why Americans pay such high prices — and why we
haven’t done anything about it."

This is probably the same reason we've taken close to 40 years to finally try
and get off our dependence on foreign oil after Jimmy Carter said we needed to
in 1978. Yet, we still pay more than we really should and haven't done
anything about it.

Why? Lobbyists, too many layers of bureaucracy, special interest groups. Take
your pick, but at the end of day, it takes a lot of people wanting to do the
right thing to make things change. In this country, that's a lot harder to do
than most people think.

~~~
redwood
One note here: we pay less for petrol than any other developing country, which
makes it harder for alternatives to make economic sense.

~~~
rfrey
Did you mean "developed countries"? Because I got tired of copying Wikipedia
([http://en.wikipedia.org/wiki/Gasoline_and_diesel_usage_and_p...](http://en.wikipedia.org/wiki/Gasoline_and_diesel_usage_and_pricing))
after:

    
    
      Country        US$ / US Gallon
      U.S.           $3.74
      Vietnam        $1.03
      Yemen          $2.76
      Turkmenistan   $0.72
      Tunisia        $3.75
      Trinidad       $2.42
      Taiwan         $3.78
      Syria          $3.15
      Saudi Arabia   $0.49
      Quatar         $0.83
      Puerto Rico    $3.63
      Peru           $3.60
      Panama         $3.14
      Pakistan       $3.46
      Malaysia       $2.31
      Indonesia      $2.23
      Egypt          $1.17

~~~
vacri
He did mean developed country. The US pays about two-thirds what Australians
do for petrol, who in turn pay about two-third what Europeans do for petrol.

The panic that the US gets itself into when discussing fuel prices is amusing
to watch. Australia is a big country with spread out cities like the US (or
even more than the US) and similar wage levels, yet we don't have problems
with post-paying cash for our fuel. In six weeks of driving around the US west
a couple of years ago, I never found a single place where I could post-pay
with cash - they were all too afraid of drive-offs. Weird.

Also, you've mangled the statistics - for example, you've used Vietnam's price
per _litre_ against the US's price per _gallon_.

~~~
matwood
_I never found a single place where I could post-pay with cash - they were all
too afraid of drive-offs._

Many municipalities in the US have made post-pay illegal, so even if gas
stations wanted to offer it they couldn't.

~~~
rospaya
Excuse my ignorance, but what does "post-pay" mean?

~~~
khuey
Paying for the gasoline after you put it in the vehicle. At most gas stations
in the US, if you want to pay with cash, you park your vehicle at a pump, go
inside and prepay a certain amount, fill up your vehicle, and then go back
inside to collect any money you didn't spend.

------
jakeonthemove
I always had the idea that American health care is more expensive because
there's not much competition - there are just a few major companies that
control the pharma industry and the hospitals, and it's pretty much impossible
for someone to just barge in and start offering their services at a lower
price - they'd have to pass by the government first (with their impossibly
high fees and heavy regulations), then if successful, they'd be harrased to
bankruptcy by the established monopoly.

It's much easier to open a private practice or hospital in the EU, for
example...

------
known
Rates in India's best hospital [http://www.aiims.edu/aiims/hosp-serv/hosp-
rates/revised-rate...](http://www.aiims.edu/aiims/hosp-serv/hosp-
rates/revised-rate-list.htm)

------
foogoo1
FWIW, its roughly $100 or even less in India.

Granted, the quality of medical care varies by a lot in India, but there are
places and doctors in India who are so good, that if I am sick, all I want to
do is take a flight back home...

The lack of health insurance in general in India ( now, it is being sold to a
growing section of the population ) has meant that prices are comparitively
lower ( though, they are really rising these days ).

------
foreverbanned
Reminds me that according this NYT infographic :

[http://www.nytimes.com/packages/html/newsgraphics/2012/0115-...](http://www.nytimes.com/packages/html/newsgraphics/2012/0115-one-
percent-occupations/index.html)

about 20% of physicians are in the top one percent. This is the highest
percentage of all occupations.

------
dhughes
If there was medical procedure that would cost a lot in a hospital an MRI
would not surprise me, it such a large powerful, power hungry, complex device
I can't see how it couldn't.

I wish each person could get access to an MRI each year it would be nice to
track your health visually.

~~~
yummyfajitas
The capital costs for an MRI, while large, are not the biggest part of the
price. I had an MRI done in Pune (with a good machine, 3T/32 channels) for
6500rs/$130.

Labor costs are a biggie. In the US, you need to pay technicians high US
salaries, in the $60-70k neighborhood from what I hear. In Pune, the
technician is almost certainly poorer than 95% of Americans. The high ratio of
capital costs/labor costs also causes higher utilization of the MRI - in the
US, many MRI places are 9-6, I had my MRI done in Pune at 9:30pm, and someone
went in after I finished.

Labor costs are actually a much bigger deal than GDP figures would suggest.
High skill individuals get a much bigger premium in the US than most of the
rest of the world. A top 1% person in the US gets $384k/year, in Canada only
$181k.

[http://www.statcan.gc.ca/pub/75-001-x/2007109/article/409688...](http://www.statcan.gc.ca/pub/75-001-x/2007109/article/4096885-eng.htm)

<http://www.nytimes.com/2007/03/29/business/29tax.html>

~~~
Anechoic
_in the US, many MRI places are 9-6_

A nit, but is this actually true? I've had 7 MRI's (5 health-related, 2
research-related) and only one of them was during business hours. I've had
MRIs done at 9pm, 11pm, 1am, 4:30am, 6am etc.

~~~
rdl
Other "special" things about MRI:

1) The trucks -- a lot of times MRI trucks are driven around to various
hospitals, and scheduled in advance, for non-emergent studies. These obviously
get scheduled during "working hours", and then the emergent off-hours MR
studies are done by transporting the patient to a higher level facility and
thus might get shot whenever.

2) The whole "doctor owned imaging center" scam or "perverse economic
incentive", where doctors own imaging centers and then refer a lot of patients
to them, increasing the use of the technology for basically no need. These are
easy to schedule during working hours, too.

------
kingsidharth
On a related note, medical toursim is a great business/startup opportunity for
other countries. Let them spend a weekend in a new city and get that dental
filling done for far less cost. It's $4 in some medical colleges in India.

------
seanieb
GlaxoSmithKilne Ventolin Inhaler USA -$41 Ireland ~$10 France -$10 Canada -
$10

------
dutchbrit
And that's why Obama's public healthcare idea was good.

~~~
rsynnott
The watered-down implementation, though, may not stand up; as mentioned in the
article, it will do little about prices besides force provider disclosure
(itself an important step, as markets operate more efficiently when it's known
what things cost, but not really enough).

------
cynix
It's free in Australia.

------
FameofLight
$25 in government hospital in India. $100 in Private ones.

------
zaph0d
... and it costs 200 USD in India.

------
rsanchez1
Anyone who has insurance doesn't care about the price. They only care about
the deductible. When people shop around, they look for the insurance companies
that provide the lowest deductibles and stick with them. After that, there's
no pressure on the providers to lower prices. The insurance companies in the
US don't negotiate lower prices, they just pass on the cost to policy holders
in their deductibles. The providers can increase the price without fearing
that patients will go to a different clinic or buy a different generic version
of their drug. Medical care in the US is one of the only industries where
raising the price can get your more customers, since it makes the government
push for universal health insurance to keep deductibles low.

There are a few solutions, two of which were mentioned in the article. The
insurance companies can negotiate prices with providers, or the government can
set the price. A third option is to let the patients themselves set the price
by having them shop around. The patients would put pressures on the providers
by going where they can get the cheapest MRI or the cheapest Lipitor. Then
insurance would be reserved for emergency procedures, instead of being used as
a medical credit card.

~~~
jrwoodruff
I don't know about you, but next time I need an emergency room or surgical
procedure, I'm not going to be shopping for the cheapest one. The article
addressed this - how do you 'shop around' when you're under anesthesia, and
would you really hire the cheapest doctor to diagnose your daughters life
threatening ailment? It just doesn't play out in reality.

~~~
yummyfajitas
Most medical procedures are not emergent. It's hard to shop around for
emergency care, but shopping around for everything else is pretty
straightforward.

We have strong experimental evidence that when people are not insulated from
price, they shop around and consume less medicine with no measurable effect on
their health.

<http://www.rand.org/health/projects/hie.html>

~~~
Cadsby
I agree that much of the general public is insulated from price, however a few
personal observations: (Note: I worked for 8 years for a state insurance
company and my wife has been a nurse practitioner for 12 years)

People don't "shop" for healthcare the same way they shop for televisions or
other consumer products. In fact the overwhelming majority tend not to all.
Either someone like me at their insurance company picks a primary care
physician for them, or they pick one from a list based on simple factors like
someplace convenient, seems like it's a good part of town, etc. Unless the
doctor is so unbelievably terrible, it's extremely unlikely they will switch.
My wife, who is frustrated by many aspects of our healthcare system,
attributes much of this to the complete and utter lack of medical literacy
possessed by the general population. The average person simply has no idea how
modern medicine works on any substantial level, so they have little to no
basis for making an informed decision about their care or provider. When you
are sick, even with something routine and non life-threatening, you don't
think "Hmm I could go see the doctor today because I feel awful, but I think
I'll price shop for a day or two beforehand." Even people with strong
financial incentive, i.e., people with limited means, don't do this. If a
child or loved one is involved you're even less likely to start thinking about
dollars over medicine.

I do agree that most patients have no accurate understanding of the real cost
of their care, and that more education in that department certainly can't
hurt, but no matter how you slice it, that cost is simply much higher than it
is in other developed societies, and that is a serious problem that needs to
be addressed.

Edit: Something I wanted add: I know in a community like HN, many will be of
the sentiment that if you fail to educate yourself about a product or service,
you borderline deserve the consequences. I agree with this in most respects.
However, taken to it's logical conclusion, that would require me to become an
expert on everything under the sun. I have no idea how the plumbing in my home
works, or how to do anything but routine maintenance on my car. It's not that
I lack the interest to learn about these things, it's simply that there aren't
enough hours in the day to plausibly accomplish this. When faced with the need
of a professional expert, I have to use a little common sense mixed in with
any superficial knowledge I do have, and trust that there is a system in place
that prevents me from being totally screwed price wise.

~~~
davidhollander
> _so they have little to no basis for making an informed decision about their
> care or provider_

The problem with not allowing individual choice in regards to health decisions
is illustrated succinctly by the War on Drugs.

Additionally, even if we rigorously proved that local decision actors in a
market operate upon highly imperfect knowledge when making decisions, it would
not constitute a proof that a global decision actor with access to enlightened
knowledge would be able to make decisions for them more efficiently or justly
by employing a non-market based algorithm.

> _If a child or loved one is involved you're even less likely to start
> thinking about dollars over medicine_

Why is medicine different from food, water, and shelter? Aren't those even
more important survival needs we are forced to make tradeoffs regarding every
day?

------
shingen
Want to get our costs down to competitive levels?

85% of all healthcare costs in America are for those over the age of 65.
America has the leading health care system for the elderly. We pay for 80 year
olds to have surgeries that they can't get in Canada or France.

Nobody wants to talk about it though, because it's not a nice thing to say,
that grandma is buying six extra months at a price of a million in treatment.

Socialized medicine will slice the most money out of treatment for people in
that demographic. It's by far the largest savings spot. Good or bad, you can
debate that endlessly; but that's exactly what will happen.

~~~
ktizo
If the US has the leading healthcare for the elderly in the world, how come it
comes 36th in terms of life expectancy?

~~~
adrianN
Because healthcare is but one of a zillion factors that influence life
expectancy?

~~~
ktizo
Fair point.

I still doubt that it is the extra cost of caring for elderly people really
well that is the major factor that is keeping the other costs high though.
Especially since there are less very elderly people, as a percentage of
population, than in other developed countries.

------
Craiggybear
You want to hear David Sedaris on this. He was amazed that his visits to the
dentist and to hospitals in France where so cheap they didn't even bother to
charge him. He had to force them to bill him and it would be for tens not
hundreds or thousands of dollars.

Social medicine works in Europe and in Cuba, where I've also seen it first
hand. This is why it is so important to preserve the NHS here in the UK.

