
Heart Surgery in India for $1,583 Costs $106,385 in U.S. - danboarder
http://www.bloomberg.com/news/2013-07-28/heart-surgery-in-india-for-1-583-costs-106-385-in-u-s-.html
======
DigitalSea
The first supposed fact thrown around in the medical costs argument like this
is, "Well in India their cost of living is lower, so they charge considerably
less, yadda yadda..." but it's obvious the price difference goes way beyond
any cost of living gap. That's over $100,000 in price difference, while it is
true the cost of living (salary, prices of every day items) in India is
considerably less than that of the US, the gap certainly isn't 100k+

It's comparisons like these that really make you sick to your stomach. You
don't see this kind of innovation in the American health system because it has
been engineered with greed in mind right from the start. The lobbyist super
groups, hospitals being paid kickbacks for using an exclusive medical
equipment provider, the money hungry mentality of US medical corporations is
more than obvious.

I think when your medical system becomes so expensive it's cheaper for people
to fly out of the country, pay for accommodation and even some spending money
to get the same level of care, if not higher than that of your own country,
regardless of cost of living differences and other nation specific costs
that's absolutely ridiculous. By the sounds of it, India is going to be the
new global superpower if more and more people fly there to pay for medical
treatment it benefits their economy in the end (given how a substantial chunk
of the population is below the poverty line, this might not be such a bad
thing).

A doctor trained in India is no less qualified than a doctor trained in the
US. So expertise or training is no excuse either. In-fact I've found Indian
trained specialists to be more thorough, careful, understanding and
compassionate in comparison to that of Australian trained medical
professionals (I'm from Australia). When was the last time you saw or heard of
a poor American medical specialist or surgeon?

The question is: Will America ever change their ways? Or will quality medical
care only be reserved for those who can afford decent medical insurance or
have jobs that provide fair medical benefits?

One thing is for certain, this is submission is going to garner a lot of
responses from both sides of the fence if past submissions along these lines
are anything to go by.

~~~
kamaal
>>You don't see this kind of innovation in the American health system because
it has been engineered with greed in mind right from the start.

As an Indian, I can tell you people here think the same about our health care
system. The Doctor in discussion here, Dr Devi Shetty is a sort of a local
hero here in Bangalore. And who knows in some years he might as well be a
national hero. Its basically because he seems to bring in advantages of doing
things in volume + some health insurance based innovations into the whole
equation. And I do agree that he is pragmatically altruistic. But such people
are exceedingly rare. We are simply fortunate to have him.

I've never been to US, but I can tell you the Indian health care system is if
not less is equally greedy compared to their US counterparts. Its just the
same.

These days if you don't have health insurance you are more or less screwed.
Its just like the US. I mean from whatever I've read about US so far its the
very same. Nothing changes. You just feel its cheaper as $1 = 60 rupees. There
you get a straight 60x value of your money. That is what it is at the end of
the day.

Coming to our system. Forget greed, fraud in the system is so massively high
nothing that I write here will explain it. It is extremely common for doctors
to order lab tests wholesale even if they are dead sure the patient has no
problems at all. Doctors get commissions from testing labs/pharmacies etc for
ordering lab tests, medicines. Treatment is purposefully prolonged, patients
made to eat all kinds of antibiotics, undergo all sorts of non sense tests
because doctors get commissions for it.

The fees for completing your medical course is astronomically high. Capitation
fee often runs in crores, the net fee by the time you finish your MD is so
high no doubt most doctors have to practically turn into crooks to get
something out of it. Add to this nearly more than a decade of studies sets a
perfect stage for these sort of activities to happen.

Its just the same old game, as you see in US. Just served differently.

~~~
acchow
> You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x
> value of your money. That is what it is at the end of the day.

I find the vast majority of people are tripped up by currency conversion, but
I'm surprised to find this on HN. In Japan $1 = 100 yen, but certainly I don't
feel I have 100x in buying power. A bowl of ramen will cost me $8 in SF; an
equivalent bowl will cost me 800 JPY in tokyo.

Let's not even get started on the Korean Won...

~~~
kokey
I'm surprised that how many otherwise smart people gets tripped up by this.
The only time you can deduce something from the exchange rate is if you
compare the difference between the two rates over a longer period of time.
Then it can roughly tell you things about difference in direction of inflation
between the two countries, and the effect on wages and imports/exports. If the
difference between the exchange rate between two countries doesn't change for
a long time the prices of goods in both countries end up being roughly the
same.

~~~
endeavour
"If the difference between the exchange rate between two countries doesn't
change for a long time the prices of goods in both countries end up being
roughly the same."

Simply not true. Compare the cost of a beer in, say, Thailand and Norway. Are
you suggesting if the exchange rate were fixed they would reach parity over
time?

~~~
vbuterin
Assuming no new disruptions, then yes, economic conditions in the two
countries would eventually equalize and prices would differ by at most the
shipping cost if one of the two countries happens to have much better natural
conditions for producing beer than the other. It's because disruptions are now
becoming (have become?) the norm that equilibrium never has time to come close
to manifesting itself.

~~~
mistermann
Alcohol is a poor example because of special taxation.

The Big Mac index is better for many reasons, one being Mcdonalds is large
enough to mostly optimize everything wherever they operate:

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

------
riahi
Probably not going to get seen in this morass of comments, but I went back and
reviewed the CMS data that the article cites.

The article used the Diagnosis Related Group (DRG) 238 - Major Cardiovascular
Procedures without Major Complications. This is the best guess at capturing
the costs of "Open Heart Surgery". (CMS only releases data for the top 100 DRG
codes). "Open Heart Surgery" is a term for a variety of surgical procedures
done on the heart, including valve replacement, vascular repairs of the
aorta/vena cava/pulmonary vessels, and coronary bypass. These span a wide
variety of DRG codes, including 216-221 for valve replacement, 228 (other
cardiothoracic procedures with major complications), and 231-236 for cardiac
bypass. Assuming we are comparing the operation known as coronary bypass
grafting, then 238 is a decent enough code to use, with the proviso that it's
not the best source for data.

Looking at the numbers claimed: If you download the Excel file from CMS [1],
you can sort by DRG and Provider Name. Yes, if you search by DRG 238 and
filter by Cleveland Clinic you will get $106,385 charged to Medicare. However,
what the article completely leaves out (and anyone in medical practice will
assume) is that Medicare simply does not pay the amount covered. Average Total
Payments by Medicare: $26,898. That's how much Cleveland Clinic gets
reimbursed, on average, by Medicare for any procedure included in DRG 238.

It gets more interesting when you include all providers and sort by average
total payments. The highest average Medicare reimbursement to anyone for DRG
238 is $54,682; the lowest $13,233. Another interesting example:

In Alabama, at Brookwood Medical Center, DRG 238 covers $111,008 and only
reimburses $15,552.

These comparisons of the US system to outside countries really need to compare
average US reimbursement to their stated cost, because they sure aren't
funding an army of administrators to get the insurance companies to pay up.

In summary, you can get "open heart surgery" in the US (Alabama) for
"$15,552". I wonder what the Alabama price is if you walk in and offer to pay
cash. If you can get it at the Medicare reimbursement rate, that compares
decently to the Indian price.

[1] [http://www.cms.gov/Research-Statistics-Data-and-
Systems/Stat...](http://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-
Data/Inpatient.html)

~~~
phaemon
Why does the clinic charge that much to Medicare, if Medicare doesn't pay that
much (legally, I presume)? Is it an accounting trick or something?

~~~
apalmer
Well, probably a variety of reasons but certainly one key reason is... if you
have to ask for 100K to get 25K, then if you ask for 25K your only going to
get 8K?...

All prices are always negotiable, just that the individual consumer is so used
to not having bargaining power that they forget this fact.

~~~
jonknee
Medicare does not negotiate. The hospitals break down bills into CPT codes and
get paid the published rate for the period for codes that are accepted
(including geographic indexes and what not). It's a mess.

------
danboarder
I found it fascinating how this goes way beyond wage differences -- it's a
serious focus on fiscal efficiency. The entrepreneur behind this has opened 21
new hospitals in India focused on bringing more affordable care:

"...he has cut the price of artery-clearing coronary bypass surgery to 95,000
rupees ($1,583), half of what it was 20 years ago, and wants to get the price
down to $800 within a decade."

This leaves me wondering: Where is the innovation toward affordable care here
in the USA?

~~~
patio11
Largely, on the lower end of the spectrum. Doc in the boxes for routine acute
care, nurse practitioners substituting for doctors, pediatric medicine (+),
etc.

\+ One business model is "Pay a flat fee of $50, cash on the barrel. Your kid
gets to see a doctor in under 15 minutes. You know and we know that 98% of the
time it's just your child being sick with a routine illness. We'll write the
prescription if required and rule out anything more serious. If it is anything
more serious, we'll explain your escalation options."

~~~
eitally
As a parent of young children, I very much appreciate this option!

------
patio11
Somewhere there is a forum of doctors saying "Pfft, the US firm wants $100k
for the patient records system and the Indian firm wants $1,000. Those greedy
bastards! They live in a toxic industry which acts as parasites on us noble
public servants saving lives every day. It serves them right to deal with
international competition finally.

Let's go with the Indian bidder. What could possibly go wrong."

~~~
anu_gupta
Not sure what you're trying to say here. You seem to be trying to defend the
cost of a $100,000 operation by making a snarky comparison with outsourcing an
IT project.

Is that actually what you meant?

~~~
w1ntermute
patio11 has a long history of making snarky comments about how outsourcing to
India should not be a concern to Western IT workers because the quality of
Indian IT workers is much lower than that of Western IT workers and clients
will ultimately recognize this and hire a Westerner instead. This is
presumably something that is quite near and dear to him, as he is an American
expat who lives in Gifu, a tiny, rural Japanese town. Since his primary income
source (outside of Bingo Card Creator and Appointment Reminder) is doing
consulting work for Western customers, it's very important to him that they
pick him over Indian consultants based on how good he is, since hiring him
presents all the same issues with respect to time zone, distance, etc. that
hiring an Indian would.

He probably experienced a lot of difficulty initially in acquiring customers
(who opted to go with the much cheaper, Indian consultants), which is why he
has such an oversized Internet presence, including on Hacker News - it has
helped build a brand for himself that isn't location-specific.

~~~
patio11
My long history of comments on the issue generally references my time at the
old Japanese day job, where I was pressganged into dealing with our Indian
subsidiary and asked to shepherd the five folks who came to work at our Nagoya
location from it. This is what I was doing during three years of 100 hour
weeks.

A more charitable read of my old comments would be "The project(s) were beset
by communication issues, terribly managed by the Japanese company (which, in
the fine tradition of Japanese companies, I'll take blame for since I was
unable to resolve it despite trying), and additionally undermined by pervasive
competence issues."

I'm not talking my book here. In the first place, I don't have a book, as I no
longer consult. In the second case, Indian BPO firms are less competitive with
me than Chinese take out restaurants: our target customers are different, our
projects are different, our marketing methods are different, etc etc.

------
rayiner
First, adjusted for PPP that is more like $3,000. Second, nearly all personal
and professional services cost way more in the U.S. Try hiring a nanny in
India versus the U.S. and compare the prices.

In any case, whenever you talk about prices, it's important to try and think
about it in terms of supply and demand. Why might prices for similar services
be lower in India? In both countries, the price for that heart surgery is
roughly the same order of magnitude as the per-capita income. But the median
Indian is living far closer to subsistence than the median American. India's
population is 70%+ rural and slightly over 50% are dependent on agriculture.
Heart surgery isn't really an option for the median Indian.[1] While it may be
financially catastrophic for the median American, between insurance, Medicare,
Medicaid, etc, it is an option for the median American. The net result is that
demand for heart surgeries, relative to the population, is far lower in India.

At the same time, the supply of doctors is higher. Being a doctor is
considered socially desirable in India, and as a result there is a good
educational infrastructure in place and plenty of candidates.

Higher supply and lower relative demand = lower prices.

I bet you can explain a lot about the U.S. healthcare industry in terms of
regulatory issues, etc, but the magnitude of the impact of that is probably
the difference between the U.S. and the UK, not the U.S. and India.

[1] It should be noted that when people give anecdotal reports about what
things are like in India, there is tremendous perspective distortion. People
will often pretend like relatively well-off people living in the cities are
the "typical Indian" when in reality they're probably in the top 10%. It's as
if the vast majority of India, poor and rural, doesn't exist.

~~~
wslh
Another thing to analyze is what's called "diseconomies of scale" where costs
and/or prices rise with scale. Also many countries subsidize the health
sector.

------
kapad
Medical tourism has hurt most Indians. 1583 USD is almost 100k INR. The
average per capita income in India is 1219 USD (72k INR). This figure too is
very misleading, since poverty is a huge problem.

A very simple plotting with data from wikipedia and rudimentary extrapolation,
shows that more than 1.1 billion Indian's annual income is less than the
current cost of heart surgery. India's total population is 1.2 billion.

Medical tourism, though very fine for a lot of folks who want a cheaper
alternative, is driving up the cost of medical treatments in India by leaps
and bounds. This makes surgeries, that were already very expensive and out of
the reach of most Indian's even more expensive and out of the reach of even
more people.

Sources:
[http://en.wikipedia.org/wiki/Income_in_India](http://en.wikipedia.org/wiki/Income_in_India)
[http://en.wikipedia.org/wiki/Poverty_in_India](http://en.wikipedia.org/wiki/Poverty_in_India)
Simpel graph of the poverty data :
[http://imgur.com/JngiK8W](http://imgur.com/JngiK8W) (I used this to find the
number of people with an annual income less than 1583 USD)

~~~
sheri
> Medical tourism, though very fine for a lot of folks who want a cheaper
> alternative, is driving up the cost of medical treatments in India by leaps
> and bounds.

Any evidence to back this up? Your links and statistics are about how this
specific cost is still out of reach of a lot of people. I don't think anyone
is debating that.

> This makes surgeries, that were already very expensive and out of the reach
> of most Indian's even more expensive and out of the reach of even more
> people.

The article shows how the cost of surgery has dropped over time, and their
goal being to drop it further.

------
GFischer
I've posted about this a LOT here on HN, because I live in a country (Uruguay)
that has a good level of medicine and prices are way cheaper (heart surgery as
described would be at least an order of magnitude cheaper than in the U.S.).

One possible explanation I came up with was:

U.S. hospitals have legions of well-paid administrators doing paperwork for
insurance companies, which will have legions of people doing paperwork on
their side, and government doing its bit, and lawyers doing their thing. All
that money is obviously not going directly into healthcare, it's basically
monstruous bureaucracy friction. I suspect "real" healthcare costs, even
factoring expensive U.S. doctors, would be shockingly cheap.

There are also other "hidden" legal costs, such as the cost of malpractice
insurance, and overcosts due to doctors being extremely worried about being
sued over malpractice and ordering unnecessary tests.

Is there a "transparent" U.S. medical institution whose expense records could
be examined to come up with where all the money is going?

That said, the article compares with Ohio's Cleveland Clinic, which is the
most famous heart surgery clinic. Supply and demand alone will make heart
surgery there an order of magnitude more expensive, regardless of actual
costs. But I've heard most U.S. clinics arent that much cheaper.

[https://news.ycombinator.com/item?id=6077593](https://news.ycombinator.com/item?id=6077593)

[https://news.ycombinator.com/item?id=6019464](https://news.ycombinator.com/item?id=6019464)

[https://news.ycombinator.com/item?id=5763001](https://news.ycombinator.com/item?id=5763001)

(I was really surprised by that one, why ARE ambulances so expensive in the
U.S.?)

------
danso
Can't resist posting this anecdote from Atul Gawande's (best known for his New
Yorker medical pieces, such as the one about checklists) book, Better: A
Surgeon's Notes on Performance...at the end, he describes spending some time
in India as a visiting surgeon to see how innovation was possible in
comparatively squalid circumstances. The Nanded hospital he describes below
serves 1,400 villages, about 2.3 million people, with just 9 surgeons (Gawande
says that'd be comparable to the state of Kansas having 9 surgeons):

[http://www.amazon.com/dp/0312427654](http://www.amazon.com/dp/0312427654)

note: _It 's a little OT, but I guess it's an interesting anecdote because it
talks about how absolutely significant surgical innovation (not just, "good
for the India masses") can occur in desperate situations. I have no idea if
that applies to the state of the art of heart surgery in India._

\------------

Among the many distressing things I saw in Nanded, one was the incredible
numbers of patients with perforated ulcers. In my eight years of surgical
training, I had seen only one patient with an ulcer so severe that the
stomach’s acid had eroded a hole in the intestine. But Nanded is in a part of
the country where people eat intensely hot chili peppers, and patients arrived
almost nightly with the condition, usually in severe pain and going into shock
after the hours of delay involved in traveling from their villages.

The only treatment at that point is surgical. A surgeon must take the patient
to the operating room urgently, make a slash down the middle of the abdomen,
wash out all the bilious and infected fluid, find the hole in the duodenum,
and repair it. This is a big and traumatic operation, and often these patients
were in no condition to survive it. So Motewar did a remarkable thing. He
invented a new operation: a laparoscopic repair of the ulcerous perforation,
using quarter-inch incisions and taking an average of forty-five minutes.

When I later told colleagues at home about the operation, they were
incredulous. It did not seem possible. Motewar, however, had mulled over the
ulcer problem off and on for years and became convinced he could devise a
better treatment. His department was able to obtain some older laparoscopic
equipment inexpensively. An assistant was made personally responsible for
keeping it clean and in working order. And over time, Motewar carefully worked
out his technique.

I saw him do the operation, and it was elegant and swift. He even did a
randomized trial, which he presented at a conference and which revealed the
operation to have fewer complications and a far more rapid recovery than the
standard procedure. In that remote, dust-covered town in Maharashtra, Motewar
and his colleagues had become among the most proficient ulcer surgeons in the
world.

~~~
ctdonath
The key:

 _His department was able to obtain some older laparoscopic equipment
inexpensively._

Thanks to high-cost health care systems elsewhere spending enormous sums on
the latest & best equipment on a regular basis, older equipment capable of
facilitating very good (albeit not best possible) results becomes inexpensive.

In all the sneering at the high cost of healthcare in some areas, the
consequential benefits to others gets overlooked. If you want the very best,
yes it will cost a lot; if you're willing to settle for good instead of best,
you can leverage what those buying the best paid for. If you cut the high cost
options, the good low cost options may very well become infeasible.

~~~
scarmig
Is your claim that the existence of excellent high-cost treatment options
drive down the price of moderate good ones in the present, or that the
moderate-cost good ones were at one point paid for by being the excellent
high-cost ones? The two claims have very different policy implications.

Overall, though, we should be skeptical of device manufacturers' claims that
dumping more money into expensive equipment leads to better health. Most money
sloshing around in the healthcare system is wasted (see, for instance, the
recent counterintuitive Medicaid study results: increased health care spending
doesn't necessarily equate to improved outcomes). If we could spend 50% of the
money for 80% of the results, that'd be an amazing improvement. And that money
could be spent on other quality-of-life improvers, which very well might
improve overall population health more than that last 20% coming from
complicated medical treatments.

~~~
sliverstorm
I think his claim is both those things. The R&D of the goods was paid for when
they were originally sold as high-cost excellent equipment. Now, the existence
of even better high-cost treatment options drives down the price of the older
originally-high-cost equipment.

------
pravda
It's not greed, it's a consequence of health insurance. Get rid of health
insurance and prices would drop 10x.

~~~
sdoering
Would they? Or would the poor middle class people not being able to afford
cancer-treatment/heard surgery just have a considerably lower life-expectancy?

I am not sure, so I really would love to see the numbers/facts supporting your
statement. Would love to learn of this magic fact. [cynicism end]

[Edit]: Typo

[Edit 2:] In Germany, with full health-insurance the cost for a
Cardiopulmonary bypass are round about 30k €. So a lot cheaper, than in the
US, despite health insurance.

Just wanted to present a fact, not let my comment stand as cynicism only.

~~~
pravda
First of all, I am sure the 106K figure is a phony 'list price' figure and not
reflective of how much is actually paid.

Second of all, you ignore the incredible sums of money taken from the 'poor
middle class' and handed over to the health industrial complex.

For most of this country's history [the USA], there was no such thing as
health insurance. The poor got charity care and the middle class were able to
pay.

Why do you think cancer treatment has to be expensive?

~~~
sdoering
I am not stating, that it might drive prices down. As I would not be stating,
that it might drive prices up.

I wouldn't do this, because I do not have the necessary facts to make such a
claim.

If a health-insurance system would work right, the health insurance agency
might have a lot of more leverage in this highly regulated market, then any
individual paying for its own. But that is just an assumption.

Well your next statement regarding my ironic "poor middle class" is just that:
a statement, without any facts to support it.

I was asking for facts to support your statements. I even did some preliminary
research into the costs of comparable healthcare in Germany (where I am from).

I just wanted to learn, if a "no health care" system might work better and be
cheaper, but I will not just believe your statements, as that would just go
against everything, I value.

So I really beg you, to show me verifiable facts substantiating your
statements. Please?

------
ctrl_freak
You would think more Americans would fly to India to get expensive medical
procedures done. Or are there other issues that need to be overcome to do
this?

~~~
venomsnake
A few things:

1\. People don't know about it.

2\. Are the outcomes comparable?

3\. Legal protection - you will have hard time suing Indian specialist in
India and there won't be much damages to extract anyway.

4\. Age? A good chunk of people that need that types of surgeries are well
covered by Medicare.

5\. You also need plane tickets, recovery time and at least one companion - so
you may look at a lot higher total cost.

6\. Plain old fear/ racism.

And the moment it becomes common there will be the full media smear campaign,
scaremongering etc

~~~
seanmcdirmid
Besides, Cuba is closer. Canada is also a bargain compared to the US and you
don't even have to violate state department rules.

However, ironically enough, the USA has a booming medical tourism industry
also. At about 60-80k, it is only half as small as India (150,000), though
nowhere near Thailand (1.42 million).

------
bluecalm
Another case: I live in Poland and needed a knee surgery (arthroscopy). Costs:
-visit to a doctor and diagnosis (30$ per visit) -MRI of a knee (135$)
-surgery + one day stay in private clinic (1k$)

So now I wanted to pay for everything without help of our health care system
because that would mean waiting. When I tell people in US MRI costs 135$ in
Poland they just can't believe it and this is in commercial clinic so they
make money here, it has nothing to do with national health care system as I
didn't use any refunds.

~~~
skyjumpr
Do you mind if I ask where you went for such a cheap arthroscopy? I'm possibly
in the market for this procedure myself, trying to weigh all the options.

------
carbocation
I can assure you that the doctors doing 1-2 CABGs per day are not making
$30M-$70M/year.

Alas I don't know how much the hospital takes, but I know that there are
~500,000 CABGs per year. I suspect that we as a nation are not spending $50
billion annually on CABGs, but I could be off.

------
tsax
\- The hospital industry is a monopolized cartel - you usually need the
approval of existing hospitals in an area before you can open your own. \- The
insurance industry is a cartel - there are extreme compliance costs that only
a few big players can take care of. \- Employer provided insurance is
subsidized. \- Most 'reform' of health care in the US has punished individual
insurance holders while strengthening the employment-based insurance system
further strengthening third-party payment systems including increasing lists
of 'must-cover' mandates for health insurance. \- McCarran-Ferguson act
exempted health insurance from a competitive national market. \- The culture
and institutional incentives in US healthcare push towards extreme capital-
intensive expenditures and cut down on labor-intensive expenditures even when
its not cost effective for the procedures that the patients require. Hospital
beds get more expensive per day while extremely unlikely to succeed procedures
like proton therapy expand further.

This paper is very illuminating and comprehensive:
[http://c4ss.org/content/2088](http://c4ss.org/content/2088). Please have a
look even if you disagree with the solutions and the ideology of the author. I
assure you it will be worth your time.

~~~
tsax
Let me also add licensing regulations that require MDs for routine procedures.
Though nurse practitioners are becoming more involved and this is a good
development. Another issue which HN commenters are aware of is the AMA's
cartel monopoly on medical school seats to control the supply of doctors.

------
nazgulnarsil
"greed" is generally a code word for "incentives are too complex for me to
bother to try to understand."

------
swatkat
Jayadeva Institute of Cardiovascular Sciences and Research, a popular hospital
in Bangalore, publish procedure charges (in Rupees) on their website. Might be
interesting for comparison.

[http://www.jayadevacardiology.com/procedure_charges.html](http://www.jayadevacardiology.com/procedure_charges.html)

------
yaix
Maybe it would make more sense to compare it to prices in Europe or other
places with similar medical standards.

My guess would be $100k in the US is about $50k in other places. At least my
travel health insurence charges twice the rate if I travel to the US compared
to "rest of the world".

------
larrywright
This is over 94,000 Rupees. That is a huge amount of money in India. I'm not
sure most people realize the cost of living difference between the two
countries.

Case in point: I was in India (Chennai) for a week on business a couple of
months ago. During that time (M-F), I had a driver who was dedicated to me. He
took me to the office and back, and took me anywhere else I wanted to go. This
wasn't a taxi service, he had nobody else to shuttle around. When I was
working, he just waited around for me to call. The cost for all of this? US
$25, for the entire week. That's what I paid the car service, so he's getting
some amount less than that.

All this to say: These sorts of comparisons are not as dramatic as they seem.

~~~
lewstherin
That seems absurdly low. I stay in Chennai and typical taxi rates run upwards
of 18Rs per KM (approx 0.48US$ per mile). I agree there is a considerable
difference in the cost of living, but what you likely paid the guy was a tip
for the entire week. Even assuming the car, gas etc. was paid by your company,
the amount still seems low for a driver's fee for a week. My dad's driver
makes 11,000INR a month.

94,000 Rupees is a lot of money in India but it is not so huge either. A small
local doctor in a city will make around that money in a month.

(ps: If you actually had a guy driving you for 25$ in Chennai, do pass me his
number. I will happily use him.)

~~~
larrywright
All I know is what was on the hotel bill (Westin). It's possible that they had
negotiated a rate with the service. I did tip, based on the guideline I was
told, about 50 rupees per day.

------
joshmn
As an American. this makes me sad. Just sick to my stomach. It's just greed.

~~~
noonespecial
But its not _just_ greed. Greed is also whats driving the Indian entrepreneurs
to try to offer the surgeries cheaply and en-mass. Its more than that. Its
unfair exploitation, regulatory capture, raw corruption and senseless
parasitism. Its greed mutated and run amok. Its what happens when you get
greed wet and then feed it after midnight.

~~~
eru
Actually, in this case it is not greed in India. The guy running the show is a
`real hero'. But the US has plenty of self-less people, too.

------
randomtree
What is the survival rate in India after that procedure, comparing to the US?

My colleague _visited_ India and returned with a stomach flu, spent a week in
a hospital.

~~~
Andrenid
So because your friend ate some bad food, that country's hospitals must be
unhygenic? Yup, I totally see the correlation there.

I'm Australian, visited the US and got severe Salmonella poisoning in Vegas...
the US must have really shocking road safety laws.

~~~
pacomerh
Same here, got salmonella in Los Angeles eating at a subway. Point being, you
can get sick anywhere, other factors include your body getting used to new
organisms.

------
socialmediaisbs
Just had heart surgery. It's closer to $170,000 here in the states. :-/

~~~
firefoxNX11
Just curious - How much was it covered by health insurance?

------
joseflavio
I believe that the high medical costs are exactly the result of Free market in
the long run. Entities will always unite to get stronger, control the market
and to do so they will support little by little laws that allow this. Just my
2c, but if you don't keep your laws and democratic institutions distant from
the big money... the free market will transform in a legal monopoly.

------
teyc
This is classic disruption at work. There are many procedures e.g. cataract
surgery costs have come down but they are such cash cows that the prices were
held high. India is doing this because skills can scale if there is a system
of training. It wasn't too long ago when I read the Russians invented a
factory-line method of doing eye-surgery.

~~~
jimgardener
Five years back,my father got both his eyes operated upon for cataract removal
at Coimbatore,India as part of some free Eye camp program.This year, my mom
had cataract in both eyes surgically corrected in a private hospital in North
Kerala.They charged only Rs.9500/\- per eye,and the treatment was quite
good.Now my Mom has 6/6 vision in both eyes.

------
DanBC
People have mentioned the cost of MRI scans in the US.

How much would it cost to buy a bunch of scanners (full body, and bucket-type
for arms and legs) and employ technicians to do the scanning and offer this as
a service to hospitals?

You could have technicians working on shifts to have out-of-hours scanning.

The scans are provided in electronic format to the patient and to the doctors
specified by the patient. The centre encrypts all the scans and stores them
for X years to cover regulation and litigation.

There's a big capital investment cost, but you're not doing any actual
medicine there (no interpretation of scans, for example) and so litigation
risk is reduced. You can concentrate on churning people through the machines,
you don't have to give way to emergency cases that need immediate scans.

And the price of a scan can be listed up front.

Is this a stupid idea? (Or is it already being done?)

~~~
Steko
You've framed it as consumer friendly but basically your hypothetical shop, on
top of being another middleman, has gained a weak local monopoly on MRI's.
That sounds like it's going to be bad for both consumers and hospitals which
is why it would never happen.

As a sidenote the problem with MRI's isn't a lack of supply. A popular factoid
a few years ago was that Pittsburgh had more MRI machines than Canada. Even if
that was only half accurate it tells part of the story about high MRI costs.

------
tn13
When government enters any equation and starts over-regulating in the name of
"poor" the poor must be actually worried. Indian healthcare system is no less
greedy than that of United states, I know several examples where Doctors would
perform needless surgeries, will recommend expensive surgeries for terminally
ill patients (which makes death more painful) and so on.

Indian government is a big believer in state interference into everything but
when it comes to healthcare Indian government's approach is different. Instead
of telling private hospitals who they should be run, Indian government builds
its own hospitals. Thus private hospitals are left on their own with very
little government interference. Thus those doctors can experiment while being
very open about their experiments.

------
muzz
From the article it's not clear what the major drivers are in bringing down
the costs. What I've gathered from the piece and another link posted in the
comments:

* No air conditioning

* Buying used scrubs

* Buying in bulk, directly from manufacturers [1]

* Surgeons that work "typically work 60 to 70 hours a week" [1]

The additional link [1] seems to indicate that the innovation is simply
volume. The highly-trained surgeons perform more surgeries, the expensive
equipment is utilized more hours of the day, etc.

[1] [http://m.theaustralian.com.au/archive/business-old/the-
henry...](http://m.theaustralian.com.au/archive/business-old/the-henry-ford-
of-heart-surgery-devi-shettys-business-model-delivers-cheap-medical-
care/story-e6frg90x-1225801548287)

------
Cardeck1
I'm not gonna go on the conspiracy road but the world is functioning on the
wrong parameters. Instead of being a united civilization and help each other
in order to advance to a higher level, we are fighting each other like lions
for supremacy in every domain possible.

Our whole system is based on superficial needs and wants rather than focusing
on what we really need as species/civilization.

How can we expect innovation and progress when we can't even cross the damn
ocean without selling our souls...we can't even cross our own borders without
special rules. Not to mention that racism is high in many countries. We are
divided as hell. If an advanced race would watch us right now they would
probably laugh hard and leave.

------
barking
In my country I know of a hepatologist who claims to have seen higher than
normal rates of hepatitis B amongst people who have travelled to lower cost
countries for dental treatment.

One country was mentioned in particular (not India as it happens).

~~~
koralatov
Your comment left out the single most important piece of information: the
country in which the treatment took place. I have no plans, and thankfully no
need, to go abroad for low-cost treatment of any sort, but someone reading
your comment might, and the key fact you omitted might stop them making a
horrible mistake.

~~~
barking
I was tempted to mention it. But what I am writing is hearsay until such time
as this doctor goes public with it, if he ever does that. If it's true it
would cause a major controversy in the EU.

------
keithjia
heart surgery in China: $237.95 heart surgery in Mexico: $199 on Saturdays

WTF is the point of talking about is, such BS. Who here is willing to have
their baby girl's heart surgery done in India vs best of the US here?

------
tenfingers
I'd like to point out that the price difference is most likely to do with the
marked conditions of the health care in general, and has nothing to do with
the quality of the operation itself.

There is a big problem with health care in most countries that I've been
living into for extended periods of time (France, Italy and to a lesser extent
Germany).

Anything sorrounding "medical" and/or "health care" has a 10x-100x price
blowup, for absolutely no reason. I'm not even speaking about surgery, I can
start by phisiotherapy consumables, such as elastic bands. Elastic bands are
used in phisical rehab. They are dirt cheap, usually, if you buy them inside a
child play store. But behold, if you buy the _same_ stuff from "Thera Band",
which is officially sold to hospitals and clinics, a couple of meters of the
stuff will cost you 20-30 times more. I worked as an assistant in a phisical
rehab clinic for several years, and this kind of bullshit is _amazing_ ,
because it goes for _everything_ (air balls, plastic rods for balancing
excercises, and so on). The price inflation goes even higher with actual
machines.

There is a machine which is called "Rehab 3xxxx" (produced by a clinic around
here which I helped develop, so I won't disclose the details), which is just a
linear actuator which moves _back and forth_. Literally, nothing more. There
is an embedded controller which allows to tune the extension limits, and a
couple of ABS plastic accessories that hold to the knee, wrist, etc.

The idea is just to move the articulation, and/or rotate it, over and over.
You would think that there is something "fancy" about it, to name a few
details which I _wished_ this machine had:

* force feedback to stop the motion (right now the machine will just twist your arm as configured, no matter the force) * speed regulation (who needs it? just one speed is good enough) * some sort of patient-id so that you don't need to reconfigure it each time

But not really. Like I said, this is just a dumb linear actuator, with
incredibly cheap ABS plastic accessories and a fancy name. Price? 30k euros in
the basic kit.

The funny part: for anything medical, you have to demonstrate that this
machine is effective somehow. So we had a trial in an hospital, wrote an
article about the effectiveness (or lack thereof) and did some paperwork. The
idea is that you just have to demonstrate that it doesn't _hurt_. Of course, a
physiotherapist will be twice as effective, but it's more expensive on an
hourly basis, so that's why clinics love to buy the machine and just let
patients sit on it.

I'm literally disgusted, but I can see everything around "medical" equipment
having the same issues. All the economy surrounding hospitals, doctors and
equipment is essentially broken, because there's essentially no competition,
assured money (by the state in this case) and a lot of corruption going on
within the clinics and medical companies (unfortunately).

edit: english.

~~~
kokey
What you describe sounds a lot like the problems the developed when supplying
to government in general, whether it be IT, military, transport, etc. That
said to me the US system sounds like it's so rigged that it has developed many
of the same problems you encounter with government inflicted monopolies.

~~~
bluedino
I wonder how many medical offices with a staff of 3 have a Cisco 3950 in the
closet...

------
codex
Given that surgery costs are dominated by labor costs (surgeon plus support
staff) and labor costs 20x more in the US than in India (see:
[http://www.economicpopulist.org/content/china-and-india-
real...](http://www.economicpopulist.org/content/china-and-india-really-are-
cheap-labor-manufacturing)) is it any wonder that surgery is 10x more
expensive in the US? If the only cost were labor it would be 20x!

------
chiachun
The situation in other Asian countries like India, Taiwan, or South Korea is
nearly the same. There are still some obstables. A different environment and
unknown results may be the major ones. People should try to calculate the
overall outcome and costs and maybe come up with some good international
insurance packages.

------
tn13
One of the prerequisites for markets to work is that, both the parties should
get into a transaction willingly. That premise somehow gets violated when it
comes to healthcare. That is why there are too many market inefficiencies
which are skewed towards hospitals and insurance companies.

------
grandalf
For anyone interested, I'll perform heart surgery for you in India for only
$1200.

------
shameerc
I'm just curious to know the situation in countries like Russia and China,
because many of my friends took their medical degree from those Countries. Is
is just the education is cheaper or entire industry?

~~~
piyushpr134
I am from India. I think one major cost factor is price of medicine. In India,
you can get medicine at very low cost compared to the west. Salary and dollar
conversion/PPP are also major cost factors. For instance, a urine test costs
$1-$1.5 in India, urine culture is about $6, a USG scan is about $14. In USA,
urine routine is $30, culture is $70 and USG is $750

------
asitkumar
India is just cheap and best :> I wonder it would be great if the medical
facilities in india be improved considering the huge mass of population.

------
pawrvx
Anything you can do, we can do cheaper, and better.

------
zaroth
Bloomberg is comparing apples and oranges, to the point of caricaturization.
They are also link baiting with false statements.

First, the link bait: "The same procedure costs $106,385 at Ohio’s Cleveland
Clinic, according to data from the U.S. Centers for Medicare & Medicaid
Services." Funny thing is they actually cite their data source, so I
downloaded the Excel sheet and looked for myself. The $106,385 is the "Average
Covered Charges" for "238 - MAJOR CARDIOVASC PROCEDURES W/O MCC" at Cleveland
Clinic. If you read the definition of "Average Covered Charges", it is not the
cost of the procedure. The _cost_ , aka "Average Total Payments" was actually
$26,898. That's what medicare pays, including co-pays, deductibles.

I spent a few minutes browsing
[http://my.clevelandclinic.org/](http://my.clevelandclinic.org/) \- the Ohio
Cleveland Clinic has over 3,000 physicians and scientists, 1,700 residents and
fellows in training, with 47 buildings on 167 acres. They helped _develop_
coronary bypass surgery in 1967.

Shetty (the "Henry Ford of heart surgery") is standing on the shoulders of
giants, and as well he should. The Cleveland Clinic and Narayana Hrudayalaya
coexist symbiotically, and I'm happy we have both in the world. Coronary
bypass surgery has to be invented first at Cleveland Clinic before Shetty can
put it on the assembly line.

If you have the time, read the Cleveland Clinic's 2012 Annual Report
([http://viewer.zmags.com/publication/71bd62a6#/71bd62a6/1](http://viewer.zmags.com/publication/71bd62a6#/71bd62a6/1))
and you can see what _they_ think they are doing differently to provide the
best service, continue driving innovative research, support their local
community, and reduce costs. Take a minute to appreciate the breadth of
research that goes on in their facilities, in areas including high-performance
computing, robotics, 3D printing...

Cleveland Clinic had $228m in Operating Income on $6.2b in Revenue in 2012.
Their $6b in expenses are dominated by $3.5 billion in "salaries, wages, and
benefits" which unfortunately is not broken down much further that I could
find in the report. "Functionally" their expenses are $4.7b healthcare
services, $450m on education and research, and $663m on G&A. I was
disappointed to see their education and research expenses are less than their
G&A, but it's hard to draw conclusions from such high-level data. It was
interesting to note they have $1.6b of accumulated pension benefits, which are
68% funded.

Unfortunately there doesn't appear to be anything resembling a financial
statement on
[http://www.narayanahospitals.com/](http://www.narayanahospitals.com/).

