
The World’s Cheapest Hospital Has to Get Even Cheaper - pseudolus
https://www.bloomberg.com/news/features/2019-03-26/the-world-s-cheapest-hospital-has-to-get-even-cheaper
======
awaaz
This article is really informative, and makes me feel proud to be an Indian.
Medical care really is one of those things that no person should have to beg
or borrow for, in a civil society. We're still not there yet as a country, but
the signs are positive.

FWIW, I'm relatively well off and have medical insurance, but the cost is
absolutely negligible compared to what I hear is prevalent in the US - about
$10 / month.

It's probably just my bad luck, but I've had three surgeries in the last 10
years - an appendectomy, an ACL replacement, and a septoplasty. Each one of
these was done in highly regarded (and expensive) hospitals in Delhi - Apollo,
Max, and Fortis. Each time I walked out of the hospital without paying a
single dime. I just had to show my insurance card, and the entire stay was
cashless. In fact, after my last surgery I realised that I could have even
been reimbursed for my medication post surgery if I'd kept the receipts (which
I unfortunately didn't).

Anyhow, more power to Narayana.

~~~
steve19
I am not saying you should not be proud of Indian progress, but I suspect the
experiences of a businessman in a big city in India are vastly different to a
low caste woman with TB in rural India.

A friend of mine is a nurse who did social work in rural India. What she told
me about the local hospitals was horrifying, not just the condition of the
hospital and how patients with infectious diseases were sleeping on the
corridors because of lack of beds, but how the doctors had a total disinterest
(bordering on contempt) of the uneducated woman who she went to appointments
with.

~~~
naruvimama
The use of the word "low caste" is in quite mean considering "poor" would be
more appropriate.

Just as Black or Native American would be a poor substitute for poor american.

Or Roma/Eskimo/Greenlander/Sami for Europe

Especially considering that the current prime minister and president of India
are from so called backward communities.

India has come a long way in social development and using the "caste card" is
quite out of taste.

The word "Caste" is of European origin and does not have a proper native
equivalent.

The "caste system" itself is again a European concept imported into India to
aid the colonial powers in their divide and rule.

Unlike the persecution of the Native Americans, Blacks, Jews or Aboriginal
which were systematic state run pogroms often in democracies.

The fate of the "low caste" can be attributed to the fact that they were the
most exploited, often to the point of death or slavery under colonial rule.
While the so called "Upper caste" enjoyed second rung positions as peons,
clerks and teachers. This experience is universal in the other colonies like
Rwanda, Syria or Iraq where the words "Tribes" or "Clans" have come to
substitute "Caste".

It must be noted that the newly independent India gave all Indians of both
sexes the right to vote and went on further to provide "reservations" the
equivalent of "affirmative action". This was long before the black American
even got the right to vote. Less said about Europe the better, the "Roma"
still get rounded up and "deported" even though as EU citizens they have the
right to mobility.

"Caste" is a powerful tool for the unscrupulous politician inside India. The
excuse of colonial apologists or more markedly the evangelists (if they are
not the former) outside India.

Caste a European concept so prominent in the family names of Americans and
Europeans, has today become synonymous with India thanks to the relentless
propaganda of the colonialists/evangelists.

~~~
npmn
It is not out of taste. Caste System(Jati System) though weakened still alive
and kicking in India. (Dalits) Lowest caste layer in India is still subjugated
to things like Cow vigilantism, Honour killing, Social boycott, Caste clashes
and discrimination in various/all forms of life. It is interesting to note
that Dalits are almost always on the receiving end of these issues.

Giving example of the Prime Minister/President is equivalent to saying since
Barack Obama is the president of US, black discrimination.

PS: I belong to the so called Lower Caste in India and I have myself
experienced instances of subtle/blatant discrimination. Thankfully haven't
experienced anything serious yet, maybe because I became an Software Engineer
and now live in a major city, thanks to the affirmative actions adopted by
India, but poorer strata of lower caste living in tier-3 cities/villages face
a lot of cases of discrimination even today.

While India has a long way in social development, it still has a long to go.
This narrative of bashing Europeans/Outsiders/Pakistanis for anything negative
has to stop. Jati System has been in practise for thousands of years now.

~~~
kevhito
> I became an Software Engineer and now live in a major city, thanks to the
> affirmative actions adopted by India...

You mean from reservations in school / university admissions? Or does that
even extend to private employment? Is there widespread resentment?

I'm really curious about the parallels (or not) between racism in the US and
caste in India, esp. affirmative action. The US never really went all-in on AA
like India did with reservations -- more like pretending if we mostly ignore
race then racism will go away -- but it seems like neither approach has really
gotten to good place (yet).

~~~
barry-cotter
If you’re interested there’s an interview on the Brown Pundits Podcast, “The
Life and Views of a Middle Class Indian Dalit”,

> In this episode, I had a conversation with a middle-class Dalit who lives in
> Gujarat. For me, Dalits are people who are reported on, written on, people
> who I hear about spoken of (usually sympathetically). But I wanted to talk
> to a Dalit who was a university educated middle-class person, to zero in on
> the essential aspect of being SC in India today. At least urban India.

> One interesting observation is that his own experience in India is filled
> with slights, but not day to day oppression. It doesn’t seem the lot of
> Dalits in urban India is anything like that of black Americans during Jim
> Crow. He seemed to assume that America had solved much of its race problem
> and that that’s what Dalits should aspire to. Curiously, Americans at this
> point, at least on the Left, perceive our racial problems as dire.

[https://www.brownpundits.com/2019/03/06/browncast-podcast-
ep...](https://www.brownpundits.com/2019/03/06/browncast-podcast-
episode-20-conversation-with-a-middle-class-dalit/)

Podcast links [https://itunes.apple.com/us/podcast/brown-
pundits/id14390070...](https://itunes.apple.com/us/podcast/brown-
pundits/id1439007022)

[http://brownpundits.libsyn.com/the-life-and-views-of-a-
middl...](http://brownpundits.libsyn.com/the-life-and-views-of-a-middle-class-
indian-dalit)

[https://www.stitcher.com/podcast/razib-khan/brown-pundits-
po...](https://www.stitcher.com/podcast/razib-khan/brown-pundits-
podcast/e/59244063)

[https://player.fm/series/brown-pundits/the-life-and-views-
of...](https://player.fm/series/brown-pundits/the-life-and-views-of-a-middle-
class-indian-dalit)

------
laurencerowe
The US healthcare system is absurdly inefficient but the nominal cost
comparison given in the article is meaningless since wages make up a huge
proportion of costs in healthcare (either directly or embedded in supplies and
services.)

Nominal per capita income in India is ~$2000 while in the US it is ~$60,000.
Simplistically one would expect costs to be approximately 30x higher in the US
so a 20x difference in cost of $200,000 to $10,00 doesn't seem absurd.

~~~
riahi
Agree. I have seen estimates place purchasing power parity of USD in India as
0.3, implying that $100 spent in India purchases as much value as $300 in the
USA. This would imply a $10,000 surgery in India is somewhere in the realm of
$33,000 in the USA.

I have no idea on the DRG associated with pulmonary thrombectomy to even
estimate what Medicare allows for reimbursement, but it’s not going to be
$200,000. If I find it, I will reply to this comment with an estimate.

Purchasing power parity compared to USA:
[https://data.worldbank.org/indicator/PA.NUS.PPPC.RF](https://data.worldbank.org/indicator/PA.NUS.PPPC.RF)

~~~
riahi
I looked into the data. This would probably be under DRG 252, 253, or 254 (DRG
252 OTHER VASCULAR PROCEDURES WITH MAJOR COMPLICATION OR COMORBIDITY, 253
OTHER VASCULAR PROCEDURES WITH COMPLICATION OR COMORBIDITY, 254 OTHER VASCULAR
PROCEDURES WITHOUT COMPLICATION OR COMORBIDITY)

The medicare DRG data is available here [https://www.cms.gov/research-
statistics-data-and-systems/sta...](https://www.cms.gov/research-statistics-
data-and-systems/statistics-trends-and-reports/medicare-provider-charge-
data/inpatient.html)

Covered charges for 2016 ranged from ~$64,000 to ~$110,000, with ACTUAL
average total payments ranging $13,000 to $26,000.

This article is using differences in purchasing power parity AND the
difference in charges / actual payments to generate an eye-popping headline.
At the actual data level, India is more expensive compared to the US.

~~~
conductr
Hospitals usually lose money on Medicare and that’s part of the reason other
payors have to pay subsidy rates. Not saying they pay sticker price they are
billed but I doubt 13-26k is the average reimbursement for any procedure that
ties up an OR for a full day (according to the article).

~~~
riahi
Inpatient care for many major procedures are bundled under Medicare. This is
actually the reimbursement for the entire hospitalization.

Yes many places lose money in Medicare as it probably reimburses at around 80%
of cost but it’s the only data we have, so it provides the closest thing to a
national comparison.

My point is that what this article ultimately shows is that the cross border
comparison can generate striking numbers but almost all articles like this
never place the Indian “cheap” numbers in context.

------
smush
Compared to high margin low volume surgeries in the US, this is low margin
high volume. Its ingenious how the highest skilled individuals only step in
for the trickiest part of the surgery, but the simpler tasks like getting to a
heart are performed by lesser doctors or nurses.

Some things make sense like having medical machines maintained in house. Other
things, like sterilizing and reusing IV lines seem pretty risky. But perhaps
the risk is approachable in this case since a patient is less likely to sue if
complications arise from something that could somehow be twisted into a
jackpot lawsuit?

~~~
jrochkind1
Sterilizing and re-using IV lines definitely carries some risk. The
alternative to that "risk" in India seems to be letting most not-rich people
die because they can not afford to do those things differently. And the Indian
health service is telling him he's _still_ costing too much. The result will
be taking more risks, with some people paying the price for them. Because that
is what India can afford.

Meanwhile, in the U.S. we can afford spending two orders of magnitude more.
Something is not right.

~~~
rtkwe
For certain values of 'can afford' given the prevalence of medical debt driven
bankruptcies.

~~~
conductr
The hospital afforded to write off that bad debt; after all, the procedure was
done, doctors and nurses got paid, supplies bought

------
jrochkind1
He succesfully performed a complicated surgery for $10K that would cost $200K
in the US.

And India still can't afford to pay those prices.

The problem is obviously not that THIS guy is not working efficiently. It's
that the distribution of wealth under our planetary economic system is deeply
unfair.

~~~
thatoneuser
Idk if I'd agree that it's "unfair" because that implies there's some natural
balance we've disrupted, when in reality wealth is largely the result of labor
and ingenuity. If a group of people gets together and creates wealth for
themselves and their offspring, is it unfair that they are wealthier than the
rest of the population? That kind of thinking at some level is fundamentally
unfair itself - if you go collect and store nuts for winter you're less likely
to starve. If we say that it's unfair now that you have all these nuts and
winter is coming, then how does one provide for one's self fairly?

Wealth isn't distributed, it's created. I mean you can distribute after that
but it would be theft.

Nonetheless I hate that some people are just born into economic situations
where they are severely less able to actuakize their potential, so I share
your sentiment. I just don't like the word unfair as it seems to disregard
accomplishment and to me it demonizes people who have succeeded.

~~~
drewblaisdell
> in reality wealth is largely the result of labor and ingenuity

The greatest trick the devil ever pulled was convincing people that this is
true.

~~~
thatoneuser
OK so if humans didn't toil to create tools and housing and technology then
how did it arise?

~~~
fwip
The fundamental assertion of capitalism is that capital should beget capital.

Under capitalism, wealth is created by labor and taken by those already
wealthy.

~~~
shripadk
> The fundamental assertion of capitalism is that capital should beget
> capital.

This quote explains just half the story. The half of the story being:
"success".

Pray tell me how is wealth created by labor without someone investing the
necessary capital required to begin with? It is not like the labor worked for
free.

The "wealthy" laboured at one point to earn that capital. They just "chose" to
invest their hard-earned capital wisely which helped them beget more capital.
Upto that point, your assertion holds true.

There are many who were "wealthy" who made blunders when they did not invest
their capital wisely and lost it all. Would the fundamental assertion of
capitalism "capital should beget capital" hold true in this case? And for all
the Zuckerbergs, Jobs and Gates out there, there are a million more who
failed. Those million are proof that the fundamental assertion of "capital
should beget capital" is false.

The only assertion that fits Capitalism is "Survival of the fittest". I can
live with that!

------
jonathanyc
This was shocking to read:

> The data appear to back Shetty up. In part because its huge volumes help
> surgeons quickly develop proficiency, the chain’s mortality rates are
> comparable to or lower than those in the developed world, at least for some
> procedures. About 1.4 percent of Narayana patients die within 30 days
> following a heart bypass, according to the Commonwealth Fund, which studies
> public health, compared with 1.9 percent in the U.S. Narayana also
> outperforms Western systems in results for valve replacements and heart-
> attack treatment, the group found.

I’d always heard that although the US’s healthcare is the most expensive, it
also has the best outcome for specialist care. But the fact that this hospital
outperforms the US while charging a fiftieth as much makes me wonder how much
better the specialist care could be outside of the US given the same
resources.

~~~
mandevil
One of the most interesting discoveries in US medicine is that there is
essentially no relationship between cost and outcomes- even within the US. The
Dartmouth Atlas of Health Care has shown that there are wide price disparities
within the US (and not necessarily in predictable ways, e.g.
[https://www.newyorker.com/magazine/2009/06/01/the-cost-
conun...](https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum) )
and that they don't correlate with improved outcomes. To some extent, prices
are a random walk that is orthogonal to a different random walk that is
'quality.'

Then again, repetition helps. People who do more procedures generally get
better results. In colonoscopies, studies show that the fastest doctors also
have the lowest false positive/negative rates, because the way you get fast
and the way you get good is to do it again and again.

------
rb808
$2k for major surgery, nice! Last time I went to ER it was $2k for the
doctor's assistant to ask a few questions and put a band aid on.

~~~
rb808
Actually it wasn't a critically urgent problem but needed doctors attention.
If someone wants an idea for an app or website - a way to lookup local ERs by
price would be great.

~~~
Jorge1o1
My fear is that if hospitals start to make their prices publicly available, it
will drive prices _upward_ not downward.

Why? Because hospitals have no incentive to compete on price. The majority of
people get ambulance'd to the nearest hospital, not necessarily the cheapest
one.

So any hospital that notices it's charging less than its competitors will
raise its price, because, why not? It's a very inelastic demand.

~~~
dragonwriter
> The majority of people get ambulance'd to the nearest hospital, not
> necessarily the cheapest one.

But is ambulanced-in patients the majority of hospital business?

~~~
Jorge1o1
I suppose it depends on the operation. You might find price competition in
non-emergency operations, but price fixing in emergency operations.

------
jedberg
I've read about this "assembly line surgery" being tried in the US as well.
But the purpose was to experiment with replacing some of the more junior
doctors with technicians. For example, there would be a technician who is only
trained in opening the chest for heart surgery. That would be all they do,
going from room to room opening chest cavities. Another technician would only
do suturing at the end. These technicians would not be doctors, they would be
folks who would get about as much training as an EMT (about 150 hours).

The next step after that is replacing the technicians with robots.

The only downside to this system (robots or technicians) is how will you ever
get experienced doctors to do the hard stuff if they never get to practice
doing the routine stuff first?

~~~
chriscross
I’ve worked as a surgical technician and can say that this already occurs in
most hospitals. It was within my scope of practice to help the doctor suture
at the end of the case as well as apply staples and bandaging so that they
didn’t need to.

------
vadlamak
One of the bigger problems I observed in the US is a defensive approach
against being sued by the patient. The doctor prescribes a battery of tests
even though he is more or less sure what the symptom might be. But let's play
it safe and not get sued approach to everything! Healthcare professionals
carry insurances in millions against being sued. The cost ultimately gets
passed on to customers. Accountability is good, but not at this cost! At the
other end of the spectrum accountability is much harder in a country like
India hence the incentive to take risks.

~~~
Scoundreller
Ordering a test and not acting on the results can create liability too.

Not all tests are binary: you have to correctly interpret the levels.

And no test has 100% sensitivity and specificity.

What is clear, is that the provider can charge for these tests and their
interpretation, so it creates income.

The liability talk may be a smokescreen.

------
vadlamak
The problem I see in the US is a defensive approach against being sued by the
patient. The doctor prescribes a battery of tests even though he is more or
less sure what the symptom might be. But let's play it safe and not get sued!
Healthcare professionals carry insurances in millions against being sued. This
ultimately gets passed on to customers. Accountability is good, but not at
this cost!

~~~
cmiles74
The hospital or larger healthcare organization derives real monetary value
from the prescribing of these tests, I don't think it all boils down to "cover
your ass". In a lot of cases it's to charge more per patient.

------
bprasanna
The moment teacher sowed the seed of change: "But his attitude to school
changed drastically in 1967, when a teacher informed the class that a South
African doctor had just performed the world’s first heart transplant."

------
hinkley
I applaud the ends but I'm not sure I'm comfortable with the means.

In circles where discipline is valued, rote tasks aren't worthless.
Considering them to be beneath you can be a trap.

Those easy steps help keep you centered on your craft. They might even give
you time to prepare for what comes after. Taken too far they can rob you of
the time to pursue skill advancement, sure. But eliminating them completely? I
think that will turn out to be a mistake in ways we can't anticipate (possibly
very different from the concerns I already stated above).

------
noelsusman
>Narayana has been able to get the retail cost of a heart bypass, its most
common operation, down to $2,000, about 98 percent less than the U.S. average.

I'd like to see where they got these numbers. The average Medicare payment for
DRG 236 (Coronary Bypass without Cardiac Catheter and without MCC) is $23,500.
Something doesn't add up here. After adjusting for wage differences I'd
imagine the numbers are much closer than this article implies.

~~~
aitchnyu
There are non-assembly line private hospitals which cost 4x. Narayana doens't
have AC rooms (OTOH) and otherwise cuts cost:

> right from design and construction, Narayana Hrudayalaya has sought new ways
> to cut costs. It has kept the design compact, reduced empty spaces and used
> prefabricated structures. Also, instead of marbles and expensive furniture,
> the hospital has used simple tiles and low-cost seating, reducing the cost
> per bed to Rs 12-18 lakh, compared with Rs 60-80 lakh at other corporate
> hospitals.

economictimes.indiatimes.com/articleshow/17768149.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

------
supahfly_remix
Really interesting article. As always, the truth is probably somewhere in the
middle.

I wonder what would happen if a company known for affordable quality, like
Toyota, could make an efficient assembly-line for health care.

~~~
maxxxxx
I think applying methods that for manufacturing to healthcare is not a good
idea. Manufacturing is generally very predictable whereas health care often
isn't. We already have tried to manage software development like an assembly
line. That didn't work for software and I don't think it will work for health
care.

~~~
jolmg
> We already have tried to manage software development like an assembly line.
> That didn't work for software

What makes you say that? Assemblies like:

\- product owner writes detailed user stories from communications with client

\- developers pick them, implement them, and put them up for review

\- CI server runs automated tests

\- reviewers check the code for maintainability issues

\- QA folks check the feature from the perspective of a user, ensuring that
the acceptance criteria are met

\- product owner accepts and merges to shared branch

What problems do you see or have you experienced in something like this?

~~~
maxxxxx
The usually the part that fails is this:

"\- developers pick them, implement them, and put them up for review"

In quite a few cases it turns out that it's not so easy to implement what you
thought first because there is a bug in some system you are using or some
other component needs to be changed too and suddenly the whole plan falls
apart. There is no amount of planning you can do to avoid this. Unexpected
things come up all the time.

I am not saying that health care can't improve but by nature it's much less
predictable than manufacturing a car.

~~~
screye
I think I am uniquely positioned to refute your claims.

I was a mechanical engineer at an automobile company before moving to
software. The two are actually quite similar.

It is common to run into implementation issues when going from concept to
production.

The big difference is, being a mature branch in an area where safety is vital,
the rigor, scrutiny and time alloted to each step are significantly greater
than software.

The similarity is especially pronounced on enterprise software products that
have long intervals between releases.

A lot of unexpected things happen with cars that go into production all the
time. Thankfully cars have a lot of redundancy required by safety. So, small
problems can often be glossed over.

~~~
maxxxxx
"I was a mechanical engineer at an automobile company before moving to
software. The two are actually quite similar"

Me too :-)

Yes, things happen when you get something in production but at some time you
reach a fairly stable state and things are predictable and easy to measure and
quantify. With medical procedures you often encounter surprises.

I agree there is something to learned but it would be terribly arrogant to say
"We have figured it out for cars and therefore we have figured out medical
care and software development"

~~~
screye
> Me too :-)

I am pleasantly surprised. Always nice to see people who have made such a
transition.

I agree with you on all points here. Once in production, stability is achieved
and car companies certainly do not hold all the secrets to resource allocation
and administrative approaches to healthcare.

The degree of unpredictability is higher in software and medical procedures.
The supply chain - production approach can only get so far.

That being said, the production approach can work splendidly well for low risk
diagnoses. The production approach has already been adopted by some software
companies. Especially contract based companies that involve a well defined
repetitive grind and set of tools. Think developing a Cash-of-clans like
mobile game or making websites for certain organizations. Both industries are
quite mature. The software problem isn't interesting, but it also rarely
throws curve balls.

_______

I am going on a slight tangent, but here goes.

I think there are some medical low hanging fruits. This is especially true in
the US, where the escalation of service is extreme. Either you get no service
or a $200/hr medical expert. If the disease is going to be a low risk common
illness 95% of the time, then maybe the patient could go through a $40/hr
medical practitioner whose job would be to attends to 'easy' cases and only
escalates it to the $200/hr doctor if the case is serious enough. A similar
case applies to the ER and ambulances too. There is, "I am about to die"
emergency and then there is the "I am hurt, but 20 more minutes to the
hospital in car won't change much" type of emergency.

Off topic: But, This approach is quite similar to a popular ML approach called
Cascade Classifiers used for resource efficient applications. It is apt, that
it would come up in a discussion about how to make Healthcare more resource
efficient.

Lastly, I find the requirement of 4 year college to enter medical school to be
preposterous. It is a waste of money and time for applicants and serves only
to line pockets of academic institutions.

~~~
PorterDuff
You could surely make a case for parking the local urgent care center (and
make it 24/7) right next to the ER.

------
ausbah
to me what Shetty shows is how the power of smart and thoughtful
entrepreneurship can not only thrive profit-wise, but can produce results that
benefit for everyone even in such high risk (surgeries), low reward (large
chunk of clientele appears to be made of India's lower income population)
industry

I don't think one could naively apply his methods to the US healthcare system
and get the same results, but what he has done at least demonstrates once
again that the healthcare system is likely irrevocably broken

------
DoubleCribble
Some equipment is too expensive to be disposable and therefore requires
enhanced cleaning protocols[0], but reusing as much equipment as possible just
to save a few bucks seems penny wise but pound foolish. Why add unnecessary
risk [1] if you can easily avoid it?

[0][https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3623380/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3623380/)

[1][https://www.scientificamerican.com/article/evidence-for-
pers...](https://www.scientificamerican.com/article/evidence-for-person-to-
person-transmission-of-alzheimer-s-pathology/)

~~~
jonathanyc
Except his hospital has better outcomes for those procedures, according to
TFA.

~~~
DoubleCribble
Where does it discuss long-term outcomes in TFA? Not all transmissible disease
manifests within 30 days.

------
chungleong
Meanwhile, people in Sub-Saharan Africa manage to feed themselves on less than
a dollar a day. They must have a much more efficient food delivery system than
our own.

------
onetimemanytime
>> _The tubes that carry blood to heart-and-lung machines are sterilized and
reused after each surgery; in the West, they’re thrown away._

Just cancelled my surgery :). Seriously, this is not an area to maximize
savings.

~~~
ketcomp
It sounds like a bad idea - but scalpels and metal tools are not thrown away
either - they're sterilized. Something like a plastic tube may have 2 or 3
uses in it instead of just 1 - as long as the sterilization is within
acceptable tolerances - why not? A reusable rocket too was unthinkable until a
private company did it. One shouldn't discard experimental evidence just
because it conflicts with one's belief systems.

------
danet
Good article that raises some very good questions. I had a few specific
takeaways out of it.

>“Everyone does as much as they can,” Ashwinikumar Kudari, a senior
gastrointestinal surgeon, says toward the end of a busy day at the Bangalore
hospital. He’s just removed two malignant tumors the size of golf balls from a
middle-aged woman’s intestines—the seventh surgery he’s performed or
supervised since morning. A compact man with a trim mustache and a wry smile,
Kudari is soon on the move again, checking in briefly on a gallstone removal
next door before dashing up a spiral staircase to another operating theater.
There, he takes over from a colleague who’s struggling to locate a
particularly tricky fistula. “Our margins are low on one surgery, but because
we do so many in a day, we can make enough,” he remarks after the elusive
fistula—the longest he’s ever seen—is found, running from the man’s anus to
above his groin. By working at this pace, the average Narayana surgeon
performs as many as six times more procedures annually than an American
counterpart.

I'm wondering how overworked doctors are in these conditions, or how long a
senior doctor lasts in a hospital like this. It might be a good place to gain
experience, but how feasible it is to work there for 10 years?

>It’s all a far cry from the high-touch treatment Westerners expect, but
Shetty is adamant that none of the practices compromise safety. Sterilizing
and reusing clamps and tubing is permitted under the standards of the Joint
Commission, a U.S.-based body that vets and accredits hospitals worldwide,
including Narayana’s cardiac hub. Involving properly instructed family members
in the simplest care tasks isn’t unheard of in Europe and North America, and
some studies suggest it may improve patients’ prospects. (Unlike busy nurses,
relatives have just one person to focus on.)

I growing up in the soviet block I remember family members taking care of
relatives in the hospital, and I never really questioned this at that time.
Now looking at the western medical system, it seems like nurses are doing work
that there not supposed to be doing and there aren't enough of them all the
time.

> Yet even for bypasses—Narayana’s bread-and-butter procedure, with greater
> economies of scale than any other—Shetty needs to cut costs further, because
> Modicare will reimburse only about $1,300 for each surgery. For other
> treatments, the difference between current price tags and Modicare payment
> schedules is much wider. “They are paying less than what it costs,” Shetty
> says.

It seems that politicians have established a system that covers everyone. Not
always effective, that underpays a lot, but it's there, now as society
gradually accepts that the system is their and it is fair, it may be possible
to expand in in the next 5-10 years either with the amount of coverage it
provides or with the amount of money it pays per procedure.

------
benj111
I think they need to qualify 'cheapest' because as a Brit I wouldn't have to
pay anything (directly) for any of these things.

Now the costs of doing the procedures are probably lower, but I have no idea
what they would cost in this country.

~~~
SilasX
Somebody is paying, and even if you're not paying out of pocket it definitely
matters how much the government is paying and economizing, because they have
to stretch your tax dollar/pound too.

~~~
benj111
That's why I said "(directly)". But yes I agree with your point.

Its unclear to me whether figures quoted are prices you pay, or cost to do the
procedure. Some at least appear to be the price you pay ("Shetty did it for
about $10,000 and turned a profit"), which as I don't pay anything _directly_
, suggests that they need to qualify 'cheapest'.

