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Ask HN: Xray cost – USA $200 (13000 INR), India 1000 INR – what causes 10x diff?
93 points by user-on1 on Sept 27, 2017 | hide | past | web | favorite | 143 comments


Why would a full mouth xray cost be this different, there may be some difference in few aspects but what adds up to more than 1000% difference?

The xrays are probably almost identical. The difference is that dentists simply charge much more in the United States. The median dentist salary in the US is about $150,000 [1]. In India, the median dentist salary is 344,000 INR, or about $5,250.

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

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

For comparison the median salary for dentists in Sweden is $51 500 [0]. The reason for the high salary in the US is not the expensive education ($100 000 extra per year buys a lot of education), it's the high income inequality [1]. The expensive health care with few incentives to lower the prices of course helps.

[0] http://www.lonestatistik.se/loner.asp/yrke/Tandlakare-1241

[1] https://en.wikipedia.org/wiki/List_of_countries_by_income_eq...

I don't think "high income inequality" is much of an explanation for why someone has high income...

It is certainly a part of it, McDonalds workers earn about twice as much in Sweden as in the US. There is no good reason why a dentist should earn 10 times as much as a McDonalds worker, people still work hard to get those jobs even when they just pay 2-3 times as much like in Sweden.

I'm sure the dentist worked harder to become one, or has more talent, to make 10x more than McDonald's worker. The latter can be done by anyone... It's absurd to compare the two...

Why is the comparison itself absurd? Both are just normal people that work all day. I guess whether the dentist "should" earn 2x or 50x is a matter of values and culture. As such I find it quite reasonable to attribute the high dentist salaries in the US to the population's high tolerance of the high income inequality.

Simple question: would you prefer to have your teeth fixed by a burger-flipper, or to have your burger flipped by a dental school graduate?

Second question: would you prefer living without well-cooked burgers, or live with bad teeth?

The difference in value is there.

Nobody is questioning whether dentists should be payed more than fast food workers, it's just how much more.

Another example: brain surgeons have an average salary in the US of $450 000 [0], in Sweden it's $65 700. I would agree that there is some room for higher salaries for people with advanced degrees in Sweden, but I also think that the income inequality in the US is way too high. It's a cultural thing.

[0] https://www.payscale.com/research/US/Degree=Doctor_of_Medici...

[1] http://www.lonestatistik.se/loner.asp/yrke/Hjarnkirurg-5131

It seems like the defense you have been required to make is just proving your point. People appear almost offended and baffled at your comments which are easy to understand.

They are also overlooking the basic facts that healthcare in Sweden is significantly better than in the US despite the significantly lower pay scale, Sweden has a higher median income, and the quality of McDonalds food and service is probably better as well (it has been anywhere I have been in Europe).

I think that what people are missing is the premise of acceptable level of exploitation.

In the U.S., there is no limit on this. The violence of poverty is completely overlooked as is the incredibly uneven playing field.

The healthcare industry is set to extract maximum profit with minimum service and people who cannot afford the premiums are left without care options/face bankruptcy.

This is just one of the many forces increasing income inequality.

Similarly, education is expensive not because it costs that much but because it is set to maximize profits.

I’d say that dentists making 150k is less of an issue than the fast food workers making 1/8 of that with minimum wage which has not increased in decades and a house median cost is above 600k-1m.

Human beings are not seen as having dignity or value beyond the exploitable.

>Nobody is questioning whether dentists should be payed more than fast food workers, it's just how much more.

This doesn't actually answer any questions or address any actual issues, unless you're willing to force dentists to work with your so-called "appropriate salary" with the full force of the law.

Draconian slave camps where people are forced to practice dentistry aren't actually necessary to address the issue; we can just look elsewhere and compare.

What virtually all advanced democracies have done is rather make a judgement about what kinds of fees are reasonable to pay for dental and medical services, and limit what the national health insurance system will pay to that.

Then see if anybody is willing to practice dentistry. They usually are.

(Also, in most, if not all, of these countries, dentists are free to charge any rate they wish for dental services, and if they can find enough people willing to pay those fees with their own money, instead of using the national health insurance system, that's fine, too. But that's typically not necessary, and hence not common.)

I have known some pretty terrible dentists and they still make a crap ton of money or just rip people off. There isn't some universal truth associated with the amount of money you make and how good you are at your job. This is the entire problem with the medical industry in the United States. For the most part you can look for recommendations, reviews, and find the right physician; for other cases where options are limited or this isn't available you don't have much you can do but be ripped off or suffer from poor service when it happens. Usually poor service and being ripped off tend to go hand in hand. It's obviously not always like this, but there are conditions where you have little choice

10 McDonald's workers can't fix your teeth. 10 dentists can be equally as good at making hamburgers. They also invested hundreds of thousands of dollars into education. So yes they deserve to make significantly more money.

> 10 McDonald's workers can't fix your teeth.

But a Swedish dentist definitely can even though he just earns twice as much as the guy flipping burgers, I don't see your point. The only reason to pay a worker more is to attract more talent to the profession, and Medicine is the field that is by far the most selective in Sweden meaning that they already get the best talent. The only thing you would accomplish by paying them more is making healthcare less affordable for the people.

I like this, Here is my try:

10 CEOs can't fix your teeth.

Does sinking hundreds of thousands of dollars into education make people who studied arts / humanities deserve a proportionately higher salary as well?

Why should that education cost so much though? Not really anything, right? That's why socialized education is so valuable, because people do what they feel passionate about regardless of 'investment' cost.

Because being surrounded by nice buildings and experts in their respective fields while living in densely populated cities isn't free. Who would've thought? If you're truly passionate about something, you're not going to let something as meager as tuition cost get in the way of it.

"10 McDonald's workers can't fix your teeth. 10 dentists can be equally as good at making hamburgers."

That is incredibly arrogant and so far wrong it's not even close to the truth.

>That is incredibly arrogant and so far wrong it's not even close to the truth.

This seems like fact to me. The whole point about McDonalds is that they have perfected their processes so well that there is very little difference in quality and output between someone who has spent 20 years making hamburgers and someone who has been there a month.

If someone is capable of being a dentist, they can likely make hamburgers. The reverse is probably not true - some portion of the people making hamburgers likely don't have what it takes to make it through dental school.

How much do you know about McDonalds? These aren’t artisan burgers. I see no reason why a dentist, should he or she have the desire to do so, couldn’t be trained to perform the task that is being a cog in the McDonalds burger factory in at most a few days. On the other hand, training to be a dentist is going to take a lot longer.

Can you explain how this is wrong?

Of course I can explain it. First, it assumes that learning to do dentistry work requires something extraordinary but the only thing it requires is the resources (time and money) to go to school.

Not everyone who gets through school gets high marks, and of those that get high marks not all of them are necessarily inclined to be good with the tools they use.

I've known of some pretty awful dentists who tended to do as much damage to their patients as they did repairs. I have no reason to believe they'd be any better at making burgers or anything else they attempted to do.

And it takes arrogance to believe that a degree makes you superior to those who don't have one. The truth is it takes longer to become proficient in some skilled labor trades than it does to become a dentist, and it take more actual skills to do the work.

I've never met a dentist who could tear down a small block Chevy engine and rebuild it. Not one. I've never even met one that could change the oil on one, but I've known kids who learned how before they were 12 years old.

Finally, some of the most brilliant people in history, some of the greatest engineers, designers, and inventors, are people who spent very little time in school and none at all in any kind of higher education.

If you think everyone who's making your burgers is less intelligent, less capable, less creative, than yourself you are an arrogant fool.

Your response is all over the place and off the mark.

You sound like someone who has never had to pass advanced exams to proceed with much higher levels of education.

I have relatives who are dentists. They are extraordinary in their precision. If you think it just requires time and money you clearly will never pass med school.

Awful dentists? Yes, every field has people of bad ethics. The very word "mechanic" conjures up images of incompetent lying men who will rip you off and ruin your car. What's your point?

Arrogance - nobody said anything about better. Just better at being a dentist and that learning how to flip burgers is easy.

I know a doctor who can rebuild engines. He is also a painter and a soldier. What's your point? The intersection of dentists and people who want to mess with engines when they can easily is small. It has nothing to do with ability. Changing oil takes five seconds to learn. Have you ever diagnosed an error on a chip with an oscilloscope? I have. Does that mean you are stupid or simply haven't cared to do so?

Everyone who makes burgers is less intelligent, less capable, and less creative than me is a different statement than "making burgers doesn't require the same level of intelligence, capability, and attention to detail as dental work".

Tell me, since you're so good at rebuilding engines, how good are you at rebuilding without turning it off? Without making a mistake? Fixing engines and dentistry aren't comparable, much less flipping burgers.

The belief that there are no genius burger flippers is what is arrogant. You apparently missed that this is the point I am making.

"I have relatives who are dentists."

And that obviously influences your take on this issue. I didn't insult or demean your relatives, I just don't have good reason to believe they're "special" because they're dentists.

"The very word "mechanic" conjures up images of incompetent lying men who will rip you off and ruin your car."

"Changing oil takes five seconds to learn."

That is exactly the kind of arrogance I'm calling out here. The truth is, pulling a tooth takes about that long to learn too, and the tools used aren't that much different.

Don't believe me?

Come on over and I'll pop one of your teeth out in about 5 seconds without ever going to school to learn how and I'll use the same tool to change the oil on my lawn mower ten seconds later.

I'd like to add:

-malpractice insurance -administration/documentation costs

The procedure price in the US has to account for filing the claim, issuing the patient an EOB, then going through the adjudication process, then finally billing the patient for the copay/deductible payment, a percent of which will likely have to be written off.

Can you provide any insight into the market forces keeping dentist salaries low in Sweden? High supply / low demand / salary/insurance caps / lower cost of living / non-salary benefits / etc.? (In the US we have the opposite of these… artificially low supply, private insurance hides costs, high cost of living in urban areas…)

It's not considered a low salary in Sweden. Engineers have a median salary of $51 500 [0], lawyers $55 200 [1]. The spread between low and high salaries is much lower, and there's some discussion of trying to raise the salaries for advanced degrees to increase the incentive for education.

[0] http://www.lonestatistik.se/loner.asp/yrke/Civilingenjor-116...

[1] http://www.lonestatistik.se/loner.asp/yrke/Advokat-1066

I was thinking of this a couple of days ago when an uninsured person got an estimate of $25,000 for dental surgery. https://twitter.com/ForgetAmnesia/status/912456274532585472 https://twitter.com/ForgetAmnesia/status/912369049958584320 I wonder if the increasing specialization is driving costs up too. If you have fewer patients you might feel pressure to charge each one more instead of admitting that you picked too small a niche.

It absolutely shouldn't account for such a large discrepancy, but is the level of expertise the same? I would also expect that the US dentist has paid much more for their education.

Did the US dentist go to school longer? As I said, I'm sure they paid more. Is the US dentist more skilled at their job? Are the requirements to practice dentistry lower in India? Are the results better or worse in India?

You also mentioned the lower wealth in India. There is also a lower standard of living cost. Costs for products and services have long-since been decoupled from expenses and people charge what they think the market will bear.

Also, is there a greater supply of dentists? My understanding is that the AMA artificially limits the supply of medical doctors, but I'm not sure about dentistry. I also have no idea what it's like in India.

Given what little I know of the situation, I suspect I'd support the idea of Indian dentists making more money, not US dentists making less money. I believe teachers and medical professionals should be well paid. $150,000/year isn't that much. We have programmers who make larger salaries, and they don't even give me a free toothbrush.

Edit: Google tells me that the average salary in India is $616, so the average Indian dentist makes about 8.5x the average income. That's about $225,000 in the US.

>Did the US dentist go to school longer? As I said, I'm sure they paid more. Is the US dentist more skilled at their job? Are the requirements to practice dentistry lower in India? Are the results better or worse in India?

I assume the phrase "no amount of safety is enough" when it comes to health care is a false statement, it's an economic problem: Am I/is the population willing to pay 1000% (10x) more for say, 2% to 1% (2x) improvement chance in the person fucking up my teeth?

With that in mind, I wonder is going to school for a long time necessary? I think we have a return-on-investment curve (or time in school vs chance that the person fucks up) that plateaus at some point here. Maybe it plateaus where the Indian requirement is, and people in the US stay in school too long for very little returns.

> Am I/is the population willing to pay 1000% (10x) more for say, 2% to 1% (2x) improvement chance in the person fucking up my teeth?

As someone with permanent nerve damage from having my wisdom teeth removed that makes me look like a fucking stroke victim when I smile...yes, absolutely

Sorry to hear.

We take a risk every time we do something. It doesn't mean that you'll absolutely be guaranteed by paying 10x more that you won't have a botched surgery, it's just less likely. Someone would say they are willing to pay 10x more for 2x less the chance, given they had an accident. The problem with that was I don't think the population will be happy adopting an 80 USD toll road and $25 per gallon for 2x less the chance of a car accident, even if that could be done. I think safety tradeoff is easier said than done.

Where did you have it done?

I ask because you did pay 10x more if you had that dentistry work done here in the US and the outcome is as you've described.

Yep, in the U.S. So I suppose the slightly lower risk didn't work out for me, but if I had to advise anyone else on the hypothetical decision, I'd say pay 10x more and get the slightly lower risk. It's not enough money to save given how shitty the consequences can be.


I've been advised by a dental surgeon to not take off my wisdom teeth because of this.

Did you receive warnings about it before surgery?

This is a tough one -- inferior alveolar nerve damage is the most common long-term complication in third molar extraction -- I advise about 1% of my patients against extraction based on the proximity of their lower molar roots to this nerve. However, there is great anatomic variation in the course of the IAN such that damage to it can occur even when pre-op radiographs show that there is little risk of hitting it. (Which is to say... SURPRISE, there's a nerve where you didn't expect it!) Sorry to hear it, OP, AND I hope you don't have permanent lingual paresthesia -- having a numb tongue is nearly impossible to acclimate to...

Wisdom tooth removal is no different from any other surgery, and as such you are likely to get the same "blah blah you could even die" speech. I did.

We know that going to school for a long time isn't necessary , for the most common procedures dontists do: filings and x-rays . We know that because a few western countries, with public healthcare,have dental assistant with a 1-year degree that do those things.

I'd say that safety certainly has a price point where people will change their minds, even if they don't want to admit it.

That's fair but a major problem with US healthcare is that there isn't really many options around cost trade-offs. We have them in every other consumer industry - a loaded luxury car offers different trade-offs than a used subcompact. Why don't we have the same choices in health care?

My grandpa has cancer and is getting chemo, the chemo seems very expensive (at least 100x more expensive than the same molecules but without FDA certification in India). However, the hospital bills each intramuscular injection at $200. An intramuscular injection is the same injection as a flu shot. Now, why can I get a flu shot for $20 at walgreens but a hospital charges $200 to perform the same sort of shot with a different payload?

And why can't we trust people to do it themselves? Diabetics stick themselves with needles routinely with pretty basic training.

I wonder how much my health insurance would be if I could forego check ups, promise not to use insurance to cover on-patent medication, and DIY my healthcare as much as possible. And I'll keep wondering because apparently a lot of that would be illegal.

>That's fair but a major problem with US healthcare is that there isn't really many options around cost trade-offs. We have them in every other consumer industry - a loaded luxury car offers different trade-offs than a used subcompact. Why don't we have the same choices in health care?

Plus, the bizarre system of "You can only change once per year and in specific windows or for a major life change".

I believe the only realistic option is single payer. Elsewhere in the thread, I voiced my displeasure at using insurance for regular medical care. I think using insurance for regular care is silly. Doing so and complaining about the prices borders on insanity. It's like expecting your auto insurance to cover a tuneup.

Also, all the operational overhead in that US dentist office will cost more than the Indian side. The secretary, the assistant, the building lease, etc. (I'm not saying that we can't fix the problem of overpriced healthcare, I'm just saying it's a contributing factor)

Strangely though, the US enjoys lower prices for consumer goods like fashion brands, and consumer electronics. Nike shoes and a Sony TV will be more expensive in India than the US.

> Strangely though, the US enjoys lower prices for consumer goods like fashion brands, and consumer electronics. Nike shoes and a Sony TV will be more expensive in India than the US.

That's not strange at all. India has import duties on many goods, especially electronics.

I have been considering medical tourism for this reason. But moreover, I see doctors responding to the strangulation of the sector by insurance companies by offering less care for more money. I can go to Costa Rica and get a lot of things sorted for a fraction of the costs and many of the doctors are trained in the US anyway.

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

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

For US I get - 175350/55775 ~ 3x

For India its 8.5x

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

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

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

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

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

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

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

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

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

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

Unfortunately, no. Purchasing power differs across economies. While exchange rate correlates with purchasing power, it's merely a rough measurement, not something you'd base analysis on.

The average proportion still doesn't make sense. Because the large population depresses the national average income greatly. On the other hand if you are comparing spending power I feel it should be more accurate to include GDP Per Capita (Purchasing Power Parity) in your calculations.

US GDP per capita nominal = 57.5K USD, US GDP per capita PPP = 46K USD. This gives a PPP-to-GDP ratio of 0.8. The average dentist salary is 175,350 USD (nominal). So the US average dentist salary (PPP) is 140,280. This finally gives you a dentistSalary-to-nationalAvg (PPP) of 3.

Now, I'll do these same calculations for India. GDP per capita (nominal) is 1.7K USD and in PPP terms it is 6.1K. This leads to a PPP-to-GDP ratio of 3.6. In India the average dentist salary is 312,797 INR according to payscale. This is equivalent to 4750 USD (nominal). In PPP terms, this is equivalent to annual salary of 17.1K USD (PPP). So finally we have a dentistSalary-to-nationalAvg ratio of 2.8 for India.

So our metric is 3.0 for the US vs 2.8 for India.

Most statistics were obtained from Tradingeconomics.com which also appeared on top of google searches. I may also have screwed up my calculations somewhere, but I don't know.

A Big Mac in India costs $2.76 USD vs $5 in US. See the Big Mac Index [1]

1. http://www.economist.com/content/big-mac-index

At least when I used to live in India 6 years ago, A Big mac was a 'fancy' meal rather than the cheapest meal possible. I don't think the index applies.

Bigmac is not the cheapest meal. A double cheeseburger is about 1/3 the price.

In my case most often it’s a hygienist who takes the x-rays, not the dentist. But even assuming it’s the dentist, and the dentist is paid at 200k/y, that translates into $100 per hour or about $1.7 per minute. It never takes more than 10 min to do the x-rays, so the labor cost of a set of x-rays can be at most $20, most likely much lower.

What does the iPhone cost in India? Has Apple subsidized it?

It is the opposite. iPhone costs at least 20% more in India.

Rs. 24,490. About $380 USD.

Prices as of September 2017, currency conversion via Google on today's date and time.

where do u see a new iphone for that price in India ? For Iphone 7, I am seeing at least $1000 USD when converted from INR. Officially on Apple website.


It was the 6s which I mistakenly read as the 7s.


My bad.

There is no iPhone 7s.

True, but that didn't stop me as misreading it as the 7s. I'd already read the 6 as a 7. The reading comprehension train had already left the station.

Durable goods (especially from the same manufacturer) cost about the same across the world.

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

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

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

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

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

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

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

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

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

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

"Charging the maximum allowed by private insurance" is the same thing as competing on price. You're just competing to please insurance plans, not consumers. Admittedly, the insurance plans have every incentive to play ball: they want to brag on large provider networks in order to sell themselves to employers/consumers, and every corporation and person in the US is legally obligated to buy health insurance, so they don't lose customers by failing to deliver value for money.

And health insurance companies have capped profit rates - the only way to return more money to shareholders is to cover more expenses. A $10 treatment means the insurance company gets to send about 80 cents to the shareholders, a $100 treatment means they get to send $8 to the shareholders. Is it any surprise that they don't really care about prices when they're incentivized to make prices more expensive and the law stipulates that you must buy health insurance if you can afford it?

Yep. Before the ACA passed, 50% of my claims (of which I had many) would come back denied and I had to go through and appeal all of them. After the ACA, no denials.

However, the actual prices have gone through the roof. Before the ACA, the total amount paid to Labcorp for some bloodwork was about $28 a few years ago, same bloodwork today I get a bill for $300. This year I needed some labs where my doctor normally charges $60. However, there was one test he couldn't do and I'm a hard stick, so he told me I should just get it all done at the hospital. I know hospitals are expensive, but I figured paying another $200-300 would be worth not getting stuck twice. When the bill came it was $1150 with the special test only being about $30 out of the $1150. Insurance never would've allowed this rate before but now they're incentivized to make prices higher.

America never ceases to surprise me. It’s amazing how many people have probably died and committed suicide because they couldn’t afford healthcare.

It’s really a shame how the wealthiest nation on the planet can’t provide for its citizens.

Or it means that to become the wealthiest nation, you’ve got to be ruthless and screw the poor. This means America will be a wealthy country, shitty healthcare, literally shit on the streets and will do absolutely fuck all when natural disasters hit.

American healthcare isn't universally crappy, it's just expensive at every quality level.

I don't think America became wealthy because it has crappy social services, but I think that a crappy social safety net and a big upside to personal success makes it an environment that really gets peak performance out of driven people.

I agree that almost all medical providers that take insurance do not compete on price.

However, even for medical services that insurance doesn't cover or cash only practices, people are terrible consumers. One of the biggest problems I see is that people have no idea on how to judge a physician and take price as a proxy for quality. For example, I found out my doctor did a medical treatment (not covered by insurance) for $150. Three other doctors quoted me $750-1150. One quoted $3500. When I told my friends about this bargain they all looked at me like I was insane. When I told my other healthcare providers, they went "Who? Oh, I know him. He does that? For $150? Really?! I'll have to go see him."

With dentistry, there's often total annual payment caps on insurance and a lot isn't covered. When I managed a call center I was astounded by how much the agents paid for dental work. They would just literally see dentist referral ad on TV, go to that dentist, and then when quoted $6k, would just go "ok" and agree. Of course, I also saw many of these people pay thousands above sticker on cars with no shortage (Nissan Altima).

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

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

Household income for the average house hold has not increased that much: https://www.advisorperspectives.com/dshort/updates/2017/09/1...

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

> If the workers in a factory are paid 5x as much as 15 years ago, the lorry driver taking the goods to the shop is paid 5x as much, the shop assistants are paid 5x as much, etc, etc then the goods sold in the shop are pretty much going to have to cost 5x more than they used to.

I think that is not necessarily true in all cases: Not every cost scales the same way. If the operation depends on human labor, such as in the food industry, then that would be true. The human cost in many operations going up up 5x, yet the iPhone and the xray machine cost the same pretty much everywhere in this world. It is cheaper to obtain and use an iPhone in the US than it is in, say China.

How much does the machine is factored in as part of the bill in the US?

I don’t know, but even then the machine has to be transported, installed and maintained in the US by US labour all of which cost more. Then there’s regulatory compliance and inspections.

So sure you can’t just do a streghtforward multiple and you’re done, that’s why I said ‘pretty much’. Some of the costs might be similar, others might be 20x or more. China probably doesn’t have medical practitioner insurance or regulatory compliance inspections at all, so those costs won’t even exist.

As a person from a third world country living in the US, the subtle difference between "absolutely" and "pretty much" is exactly why I (and I'm sure, many other immigrants) like my life in the US much better. I enjoy ${k}x the pay, yet not everything costs ${k}x more. I'd have way more breathing room with that extra money here and there every day, every minute, every hour. Pretty much everything I buy, every service I use, every problem I touch costs "a little bit" less than ${k}x.

That is, other than the medical bill and the education bill, if I have my own family later on.

Absolutely. Many basic goods are priced internationally now. Aside from deliberate manipulations like import duties, things like cars, TVs, kitchen appliances, etc are similar prices everywhere especially if you minimise labour costs such as through online retailers.

Even in China salaries might be 5x higher now but also the exchange rate has halved, so foreign goods are effective 10x more affordable now. Hence cars are everywhere, compared to when I started going there when owning a private car was an impossible dream for most families and the streets only carried busses and taxis.

Usually, the productivity also increases over time so the price of the product will increase slower than the wages.

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

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

The prices are also on the same order of magnitude here in Japan, which is another country typically seen as high-cost. (the number a quick Google turned up was $35 for a panorama x-ray, before insurance)

The government health-insurance scheme also covers 70% of the costs of covered dental work and within this system the costs that dentists can charge are regulated (which in some cases leads to perverse incentives where dentists split up procedures like cleanings so they can bill the insurance for two procedures instead of one)

Note to non-Brits: NHS dentistry (and opticians) are a little different from the rest of the NHS, in that not everything is free and the NHS services are oversubscribed, so people tend to go private.

I think it's similar prices in France, xray+consultation is in the order of 60 EUR.

The nhs seems fairly impressive & well regarded internationally.

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

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

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

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

I use a private (non-NHS) dentist in the UK, my last x-ray was wrapped up in my standard check-up price of ~£50, the cost is clearly so low they can just not bother billing for it separately.

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

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

Dentist's salary guideline: https://www.careers.govt.nz/jobs-database/health-and-communi...

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

Note: NZ doesn't have malpractice insurance. [1]

[1] http://www.commonwealthfund.org/publications/in-the-literatu...

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

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

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

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

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

My (somewhat educated) guess:

1. Hospital staff bills less per hour

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

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

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

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

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

5. Greed

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

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

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

Note it might not be the greed of the hospital staff. Instead pharmaceutical companies might be charging ridiculous amounts for medication and operation supplies.

In addition, a hospital is like a company. It must try to break even. Hospital management is presured to reduce costs as we have an aging population. Predictions are medical costs for the entire population will explode. Furthermore, the cost pyramid for Healthcare is an inverse one. The 5% chronically ill take 95% of the total costs. They cannot afford to entirely pay for their care thus hospital management is forced to get these costs reimbursed elsewhere. Which might be you.

Aging population and the inverse Healthcare pyramid places hospital management in a difficult position where they would have to reduce costs to such an extent they cannot provide proper care. Their only solution is to get more money in so the debit/credit sides are in balance again.

I can assure you the healthcare industry in India is by-and-large for-profit. It doesn't mean everything has to be more expensive.

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

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

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

Your explanation lacks imagination.

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

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

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

It is quite different for other health related professions.

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

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

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

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

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

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

Mostly for the same reason a Swedish bus driver gets paid 50x an equivalent Indian one does. Protectionism. Most of the "free world" relies on this practice of immigration control to keep wages high. You really don't want a free market unless you're from a poor country.

Immigration control is not only about the job market.

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

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

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

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

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

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

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

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

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

Put very simply: It's a corrupt system.

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

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

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

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

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

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

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

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

Welcome to capitalism.

Welcome to the sunk cost fallacy!

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

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

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

Costs are as in title.

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

Europe too develops a lot of tech[1]. And uses it for a lot less than the US.

In France (Paris area), the price for a dental visit including 1-2 xrays is €42.00[2]. This is the pre-negotiated rate between dentists and the state insurer. Dentists are free to charge more but they must display prominent signage indicating they don't follow standard rates.

[1] Peruse this catalog and notice the European companies in here. http://www.medicalexpo.fr/fabricant-medical/systeme-radiogra...

[2] https://www.ameli.fr/essonne/chirurgien-dentiste/exercice-li...

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

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

Actually... kind of.

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

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

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

> spends a quarter of its massive GDP on healthcare.

isn't most of it for wasteful reasons.

>There are many things wrong with our system

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

Lots of it is made by Philips and Siemens as well as a huge number of Japanese manufacturers. GE is big in healthcare equipment too and there are many lesser known medical equipment manufacturers all over the globe.

In all it is definitely not an American affair.

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

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

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

Would you buy coca cola if it costs $15 in usa?

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

Which is around 2 times more than in India.

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




employees to deal with insurance crap.

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

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

Sounds like we are paying so much money for a for a big lie.

1. Labor costs.

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

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

Adam made an episode explaining medical costs and why it is so high. It will at least give you a different perspective into the system.


So adding on to the labor/fixed cost increase, prices are just inflated since insurance pays for them anyway. In India, people don’t really consider insurance for such routine work due to the hassle of processing the claims too.

The US health system is probably subject to the least "freedom" of any industry in the US - possibly the world.

India doesn't have socialized medicine. It's still 10x cheaper.

To compare, in Canada where medical coverage is socialized but dentistry is [usually] not, the cost of a set of x-rays (2 or 4 shots) maxes out at $100-$200 when uninsured.

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

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