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Hospital prices are about to go public in the U.S. (ajc.com)
592 points by SQL2219 20 days ago | hide | past | web | favorite | 375 comments



Pro tip: I was a neurosurgical anesthesiologist at the University of Virginia Health Sciences Center for twelve years (1983-1995). Every now and then I'd get a call from our billing office that they'd received a letter from a patient I'd cared for who was too poor to pay what our department had billed (usually many thousands of dollars: I had NO IDEA what our charges were, BTW, nor did any of my colleagues in the department). Every time that happened, I'd go over to the billing office and — without bothering to read the letter — tell our billing chief to waive all anesthesia-related charges. In other words, by my initialing a form we had, their balance due us was 0. Try it, you never know, it might work for you.


If you are a patient in this situation, there are advocates who can help you. One thing to try is to ask the billing department if they will "accept assignment". What that means is that instead of billing you their fake rate, they would instead bill you as if you were an insurer.

IMO, it is incredibly unethical and dishonest for these medical corporations to charge different fees depending on who you are. Prices should be transparent, and should be the same for everyone.

Some may argue that an organization representing a large pool of people should be able to achieve economy of scale and a better price. This seems false to me, as in reality there is only one pool of people and care provider provide care to that one pool. Its time to kick the middlemen out.


I've done that. Except I didn't know the words "accept assignment". I basically just said that I'd pay whatever they'd charge if I had insurance. So they could either accept that, or let it go to collection. And if they let it go to collection, I argued, they'd probably get less than the insurance price that I'd pay them.

And I got an adjusted bill.


God this a thousand times. How in the /fuck/ have we allowed our medical system to come to this?

I get the negotiation side of things. I get that the leverage insurance companies have is the culprit. But at the end of the day, hospitals just upcharge so they have the upper hand in negotiation. There’s no reason that individuals who choose not to go the insurance route are artificially charge X times what insurance companies are. There’s no excuse.

Charge them the cost of the procedures with whatever markup is reasonable for the hospital to stay in business. It shouldn’t be any other way.


When you remove the middlemen, what will you replace them with?


Tiny bits of software.


What's the purpose of the software?


Replacing the middle men


Middle man out algorithms


Is the software written by people who would not profit from the software?


Could be an open standard


This is quickly degenerating into... an xkcd comic


Middlemen are not indispensable - they need to justify their existence not others to justify their absence. The whole point of cutting out the middlemen is to force them to go from a parasitic role to offer some sort of actual utility for their price.

If the middlemen have something of value to offer they have little to fear - just someone to buy gasoline by the tanker for instance keeps gas station middle-men safe because they provide both a workable connection between logistics of the very large production and consumer scale amounts - in addition to the distribution.


My experience is that hospitals have switched to a zero tolerance policy around this in the last few years. They'd rather make no concessions and sell bad debt for pennies on the dollar than set a precedent that there are alternative channels of payment. The one lifeline they give you is an interest free loan. From an economic standpoint, I'm sure this optimizes revenue. From a humanitarian standpoint, it's disturbing. I'm not arguing healthcare should be free or discounted, but when you receive a $500 bill because the on-call ambulance wasn't in network (though the others are in-network and would have cost you $50) it is hard to justify zero tolerance. We have a gold plan and I can't count the times we've been subject to loophole fees like this.


Caveat: All hospitals not managed identically.

I'm sure there's a lot of varying billing policy, hospital to hospital. And varying ability to financially write off care.

As a gut guess, I'd expect rural hospitals to be the worst about this and suburban the best.


I'm sure this is true. We've (unfortunately) now experienced this at 4 different hospital systems. The customer service is alarmingly similar.

Hospital: "Call your insurance company and ask for a break" Insurance Company: "Call the hospital and ask for a break"

Also, 2/4 of these hospitals had outsourced their billing which means they can't even make decisions on behalf of the hospital (and have a disincentive to write anything off). Seems like a structural way of avoiding writedowns.


Was going to ask about outsourcing. I don't know the market on provider billing, but I'd assume there are some companies that manage a number of facilities.

And wow, does that search bring up a lot of astroturf: https://www.google.com/search?q=list+of+medical+billing+comp...


Thank you for doing that. As somebody who has recently received a discount from their dentist on an emergency procedure, I can't begin to tell you how much we as patients appreciate these acts of consideration and kindness. Even if we can't fix the larger, systemic problems in healthcare right now, these individual acts of kindness can really make a big difference in somebody's life.


Doctors don't know the prices, and neither do the customers (not without doing a lot of homework that can't be done during emergencies). Even when you know the list prices, the actual prices your insurance negotiates are almost certainly different, so asking for list prices isn't enough.

Basically, in the U.S. the healthcare system is not exactly a free market as pricing signals are unclear, and most consumers have no idea how or inclination to price shop as they have been trained for decades to not bother. The problem is now not just a matter of how insurance is structured, but cultural.


My wife owns and operates a private medical practice (she's an audiologist), and it's insane the way she has to do billing and accounts receivable.

When a patient asks about prices she quotes them her standard price for the necessary services and calls their insurance company to confirm that the patient is covered and check what kind of copay the patient needs to pay. Assuming the patient is satisfied with the results of that call she provides the services, bills the patient for their copay, and files a claim with their insurance company.

Several months later (and no real way to predict when), the insurance company will provide an "offer" for probably somewhere around 60% of the quoted price (though this varies dramatically as well). She can accept the offer, in which case she's inevitably required by the terms to eat the difference instead of attempting to collect the balance from the patient. Or she can reject it and attempt to collect from the patient, in which case they will likely be very confused and angry as to why their insurance isn't being accepted, despite her explicitly confirming that it would be covered before they purchased her services.

To be clear, none of this is negotiated or agreed upon in any meaningful sense. She doesn't have any special relationship with any insurance provider. Instead, the providers use their massive power differential to dictate terms. She wouldn't be able to stay in business if she didn't accept at least some insurance, but they'd be quite happy to never write her another check.

She knows what her price schedule for everything is, but it doesn't end up mattering that much since she doesn't know when or how much she'll ultimately be reimbursed except in an extremely broad aggregate sense. The worst part is that she has to dramatically overprice her services so that she can ultimately get adequately reimbursed to keep the lights on, which just ends up hurting the patients who don't have insurance.


In a world of pre-1990s, high-deductible, 80/20 insurance, this would happen less as the insurance company might not do the 800lb gorilla thing until the patient maxes their deductibles, and high deductibles give the consumer a strong incentive to negotiate directly with the provider.


It's insane more people haven't realized this. All you need to do to fix our healthcare system is bring transparency to prices and have insurance actually be insurance again instead of health plans. I have multiple anecdotes from my own life where I didn't care about the cost of something due to my insurance paying for it (and in some instances not being able to be informed of the price beforehand). When you have a whole country like that it's easy to see how things have gotten to this point.

The only downside is I don't see how it would fly politically...which is a big downside.


Piecemeal. First require more price transparency. Then stop incentivizing the HMO/PPO type of insurance.

The counterexample is Medicare and Medicaid, which (CMS particularly) are exhaustively transparent (to provider and patient alike) regarding what they cover, pricing schedules, etc. Having architected revenue cycle platforms, I can say that Medicare was almost ridiculously easy to work compared to private carriers.


It should be sustainable for patients to directly pay for the provider for the services directly for most medical care.


Yes, but that would require lower costs (prices). That we could get if pricing were more transparent. I believe that will require moving back to high-deductible 80/20 style insurance.


I think its the opposite. If you made people pay for it, they wouldnt consume it, and demand would drop, and prices follow.

You cant have your cake and eat it too. If you want prices to go down you have to say there are things you wont do anymore.


This was my experience when my partner received treatment and the insurance company refused to cover the anesthesia charges (they claimed anesthesia was optional for the procedure and thus wasn't covered). The anesthesiologist's office was surprised that it wasn't covered and waived the charges.

It was the only bright spot in a prolonged battle with the insurance company and the hospital.


Optional anesthesia may be a new trend. Restraints and a bite belt are cheaper, but the hospital would figure out a way to milk that too.


Bite belt sanitation fee: $300


Another big tip: if you need an X-Ray or any kind of exam done, don't do it in a hospital. Go to a clinic (if applicable of course) that specializes in those kind of exams and is covered by your insurance company if you can, it will cost a lot less usually. You can usually call your primary and ask them what clinics or labs they recommend. You'd be surprised what a huge difference that makes.


After we establish transparent pricing across the board, we're going to have to deal with the reality that some folks seek care without having any ability to pay for services.


Yes, we will, and that will hopefully lead to a more important conversation about what the priorities of a society's medical system should really be, or how a society should prioritize funding medical services if you want to take a different approach.


Some folks need care without having the ability to pay.


by my initialing a form we had, their balance due us was 0

That is very nice of you. I hope others like you in positions of power do the same!


As I recall, every fellow attending did exactly what I did whenever they received a letter like that. It happened so infrequently, and our department billed so many tens of millions of dollars/year, it wasn't even a ripple in the pond.


it wasn't even a ripple in the pond.

True, but it did make a difference to those people you helped! so yeah, kudos to you.


I'm up voting your comment, people on this site can be ridiculous.


After thinking about this, I realized he probably didn't do the job for free. Even though "anesthesia" is broken out as a line item on the bill from the hospital, it's not what the anesthesiologist gets paid. It's probably not a passed-through charge like it appears to be.


We were on salary, not paid by the case.


Like our elected officials for example


I would prefer not resorting to begging.


I was in a hospital in Singapore recently, and the prices for doctor consultation fees, staying in a room, and even certain tests were listed right at the front of the emergency room desk.

After the patient I was with was stabilized, the nurse confirmed with us verbally what the rough cost should be for the rest of what the doctor prescribed, and asked if we wished to proceed. We could have said no and gone elsewhere if we wanted, since the patient at least was relatively stable and we knew what was wrong.

I want this experience to be the norm in the USA.


Where I live you know the cost before you go to the doctor since you will only pay a symbolic sum of 30 USD even if the visit ends up with something like a life long cancer treatment. If you need medicine you will pay at most 120 USD per year regardless of the costs.

The idea that your access to healthcare should be linked to your own or your parents financial is crazy.


I agree in principal to an extent - however economics need to be tied to the end product somewhat. Otherwise many people would opt for $100k healthcare cost (at the expense of the public) to extend their life for a few more months, this is not reasonable. Resources are finite - therefore we need appropriate allocation.

In the end I agree that a basic safety net is necessary and serves a greater good - providing things like normal checkups, preventative services, and acute trauma care is reasonable. However $200k for a second heart surgery for someone who hasn't taken heed of earlier exercise or diet advice by a practitioner should not be supported.


Serious question: Do you live a perfect life? Do you exercise daily? Do you never eat processed meat (linked to cancer)? Do you never drink soda (linked to metabolic syndrome)? Do you not smoke? Do you not drink any alcohol (linked to cancer)? Do you live close to your work so as to minimize the time spent in a car (car accidents are a major cause of preventable death)? Are you not overweight, even a little? And so on.

Do you think that someone who follows all but one of those rules still deserves healthcare? All but two? What's the moral difference between someone who smokes and someone who hasn't taken heed of diet/exercise advice after getting heart surgery? Where do you draw the line?

It's easy to say, "I don't want to pay for the healthcare of some hypothetical 'slob'". But make it real, consider what this actually means, and I think it's not something most of us want.

None of us is perfect. I'm sure that even olympic athletes occasionally eat bacon. Let he who is without sin cast the first stone, right?


> Do you think that someone who follows all but one of those rules still deserves healthcare? All but two? What's the moral difference between someone who smokes and someone who hasn't taken heed of diet/exercise advice after getting heart surgery?

Yes. Yes.

Moral difference no idea, but neither one should expect to have society foot the entire bill for their bad habits.

> Where do you draw the line?

Probably around morbid obesity that's unrelated to genetic/chronic issues.

> Let he who is without sin cast the first stone, right?

By setting an unreasonable standard and saying no one under it has the ability to cast judgment is extremely anti-intellectual. If 2 people were telling you about health habits and one of them was an olympic athlete (who occasionally ate bacon), and the other was a random overweight person from the street, whose advice would you give more weight to?


> Probably around morbid obesity that's unrelated to genetic/chronic issues.

The jury is still very much out on how common this is, isn't it? Who is going to make the decision of whether I am "at fault" for my obesity?

Also how many people actually choose to be morbidly obese? Like, suppose I am genetically predisposed to like "unhealthy foods" (scare quotes because we don't really know what that means). Does that excuse my obesity as genetically caused? How are you going to tell the difference between someone who "selfishly likes" unhealthy foods and someone who can't help themselves? More to the point, is there a difference?

> By setting an unreasonable standard and saying no one under it has the ability to cast judgment is extremely anti-intellectual. If 2 people were telling you about health habits and one of them was an olympic athlete (who occasionally ate bacon), and the other was a random overweight person from the street, whose advice would you give more weight to?

In the face of this claim that my argument is anti-intellectual, I think I get to be pedantic and say that this counter-argument is a straw-person and equivocates.

I am saying that I don't think an Olympic athelete should pass moral judgement on other people. But of course an expert can pass intellectual judgment on ideas (e.g. "candy is healthy").

I can't believe I'm here as an athiest defending Jesus, but there you go. :)


> Also how many people actually choose to be morbidly obese? Like, suppose I am genetically predisposed to like "unhealthy foods" (scare quotes because we don't really know what that means). Does that excuse my obesity as genetically caused? How are you going to tell the difference between someone who "selfishly likes" unhealthy foods and someone who can't help themselves? More to the point, is there a difference?

I'm sorry but this is insane. Are we just abolishing any notion of personal responsibility whatsoever? I can't and won't argue from that first principle so we're going to have to disagree here fundamentally.

What if I can't help myself but grope women? What if I'm genetically predisposed to violence? Or kleptomania? Those things also impose a heavy cost on society, but if I just can't help myself, am I really at fault?

> How are you going to tell the difference between someone who "selfishly likes" unhealthy foods and someone who can't help themselves? More to the point, is there a difference?

Of course there's a difference. If your willpower is not sufficient to correct your obesity, then you should take other, more radical steps that do. And if you don't, then you're just selfishly externalizing your problems to society.

> But of course an expert can pass intellectual judgment on ideas (e.g. "candy is healthy")

Good, at least we can agree on something. So to answer the first part of your post, you should ask an expert on obesity. I'm not one, so if their judgment differs from mine, I'll stand corrected. But until then, I'll be of the opinion that most obesity cases are not genetic.


> you should ask an expert on obesity. I'm not one, so if their judgment differs from mine, I'll stand corrected. But until then, I'll be of the opinion that most obesity cases are not genetic.

You're saying you have no expertise in this, haven't spent any time reading the literature or consulting with experts, but you nonetheless are going to continue having a strong opinion on this question? What is the basis for this opinion on a question of fact? Hopefully it's not than the fact that fat people are icky and so must be morally at fault for their failings?


I can ask you the same thing, but in reverse. What is your strong opinion on believing that people should have no responsibility for the obesity, when we know it is caused mostly by over-eating?

Why do you presume people are completely hopeless at controlling what they put in their stomach?

How many experts did you consult with to form your opinion?


> What is your strong opinion on believing that people should have no responsibility for the obesity, when we know it is caused mostly by over-eating?

We don't know that obesity is caused mostly by over-eating.

Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone.

This is not obscure knowledge. Literally if you google "what causes obesity?" you'll get pages like this: https://stanfordhealthcare.org/medical-conditions/healthy-li...

> How many experts did you consult with to form your opinion?

I spend a lot of social time around doctors, and I read a fair amount of medical literature (for someone who isn't in the medical sciences, anyway).

I am not claiming to be an expert, but I am claiming to be somewhat informed, yes.

I am also claiming, more strongly, that before we as a society punish someone for causing something we'd better be pretty damn sure that the person actually did cause the thing, with mens rea and so on. I am claiming that the scientific evidence is not there for obesity.


> We don't know that obesity is caused mostly by over-eating.

No, that part is obvious and we do know that more calories results in more weight. There's no debate. The only debate is in what causes over-eating.

> Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone.

Also flat out not true. You're creating some ridiculous standard for "knowledge" when in reality, you only have to have "good enough" knowledge in order to be healthy and not obese. Most people can easily adhere to, but for whatever reason, don't.

> This is not obscure knowledge. Literally if you google "what causes obesity?" you'll get pages like this: https://stanfordhealthcare.org/medical-conditions/healthy-li....

Yes, and? The answers are not equally weighted. Just because there are 3 answers, doesn't mean each answer is equally responsible in the cause of obesity.

> I am not claiming to be an expert, but I am claiming to be somewhat informed, yes.

I am claiming the same. My parents are biomolecular scientists and for them it is not contentious that overeating causes obesity. If we're giving weight to anecdotal evidence, I'm entitled to at least give my own evidence the same weight as you do yours.

> I am claiming that the scientific evidence is not there for obesity.

And there are people claiming that anthropogenic global warming is a myth, despite scientific evidence otherwise. However, I'll take claims that are true (overeating causes obesity - replicated many times), over claims that may or may not be true.

Please realize that you're in the minority on this, but the science is already settled. It's ok to admit that you're wrong.


>> Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone. > > Also flat out not true. You're creating some ridiculous standard for "knowledge" when in reality, you only have to have "good enough" knowledge in order to be healthy and not obese. Most people can easily adhere to, but for whatever reason, don't.

OK, this is a concrete claim that we can test: "most people can easily adhere to a 'good enough' diet/lifestyle to avoid being obese".

If this were true, then there would exist a protocol that "easily" results in lasting weight loss for most people, right?

Does such a protocol exist?


From one of the world's foremost experts on the brain: https://www.wnycstudios.org/story/revising-fault-line


I'll gladly read that in a textual format. Podcasts tend to be long-winded with a lot of useless fluff.

If you have a link to one of his papers, I'll gladly peruse it.



BTW this podcast episode is literally talking about exactly the question that you were asking, namely, to what extent can people have responsibility for actions?

Might be worth your time at 2x speed. Or not, I dunno.


The whole point against it is that there are precedents being set regardless of what you think is 'right' it will start to apply to other things in the model that you agree with far less - especially when they go off of assumptions that turn out to be objectively wrong.

It is essentially a bill of rights thing - either you support universal rights for everyone or you support them being taken away whenever convenient a.k.a. no rights at all for anyone.

Just go back as shallowly historically speaking as AIDS in the 80s. "Only gays and drug users get AIDS so why should we pay to help those degenerates?" sounds downright satirically stupid but that was essentially a real viewpoint and sadly still is really. Judging the 'guilt' of patients is a very dangerous thing for a society to do and doesn't help the underlying health problem at all.


If you ask the public to subsidize your personal expenses, the public inherently has the right to set reasonable limits on that subsidy. If you want to be free from those limits, it's your responsibility to pay your own way.


No I don't live a perfect life, I try to do better when afforded the opportunity - but that's besides the point. You're right - I over extended the scope with my initial statement. An in no way do I think the individual without sin is the one who should be making the call either.

However, I think if we gather a pool of public funds there needs to be a priority system or some feedback loop or liability included (back to finite resources being at stake).

Those things like sugar may come with a tax so that respective procedures are funded by it. Likewise for driving, insurance is required. For diet and exercise, maybe you can get an income tax credit for following certain things.

Not perfect, but I think we can get better then a simple pool that's support for everything and anything.


> However $200k for a second heart surgery for someone who hasn't taken heed of earlier exercise or diet advice by a practitioner should not be supported.

I disagree that failing to adhere to a certain diet should be punishable by death.


> Where I live you know the cost before you go to the doctor since you will only pay a symbolic sum of 30 USD even if the visit ends up with something like a life long cancer treatment. If you need medicine you will pay at most 120 USD per year regardless of the costs.

Then the problem is you have no pricing mechanism for determining how much the provider should actually be paid. If you offer less than what people value the service at, you'll get shortages (or, in this context, waiting lists and less life-saving medical R&D). If you offer too much, you're overpaying (see also US government contractors).

Governments in Europe apparently solve the "paying too much" problem by systematically underpaying, but that doesn't work if everybody does it. The US can't subsidize your medical R&D if they're doing the same thing.

> The idea that your access to healthcare should be linked to your own or your parents financial is crazy.

I've never understood why people have this idea about healthcare but not even more immediate necessities like food and housing. It's not as if the solution you're proposing is even analogous to the solutions we use for the poor there (i.e. free clinics akin to homeless shelters and soup kitchens). If the problem is that free clinics are poorly funded, why isn't the solution to fund them better rather than nationalizing the entire healthcare system?


> I've never understood why people have this idea about healthcare but not even more immediate necessities like food and housing.

Hmm but I have the same view for food and housing. Where I live if your mother doesn't have allow money to buy proper food the government will contribute (both for food and housing).


The difference is that the government doesn't take over all farms, restaurants and grocery stores and require you to get your food from them even for everyone who can afford it themselves.


Hmm but the government also doesn't take over the medical facilities where I live? Most medical facilities here are normal private companies (some privately owned, some publicly listed etc).

So what do you mean?


With the difference that a long-cancer treatment might cost hundreds of thousands of dollars in the US and simply bankrupt the hospital.

Its easier to eat up cost if its a lot lower and has caps. The US has no apetite for those level of restrictions.


Not sure if you are joking but the hospitals are paid by the government for the provided services (via tax money). Obviously a life long cancer treatment will cost much more than 30 USD.


If the government has a final say, then it has to restrict supply to keep costs down. It cant say yes to everything.


Doctors are expected to give the proper amount of care so they do that. Doctors doesn't care about what this will eventually cost for the government. The doctors work for private companies so the have no incentive to limit the care. They also have no big incentive to provide more care than needed.

Anyone can go to a doctor to get an appropriate level of treatment. If you want more than that, to the degree that you want to waste your own money, then of course you can do that by paying for it out of your own pocket.

It's funny that we are having this discussion. This is a solved problem in large parts or the world and the only reason it's an issue in the US is due to people being crazy.


I don't think its a solved problem at all. Healthcare costs are an issue in terms of spending per capita in the whole world. And the "whole world" depends in great amounts on the pharma and medical research that is developed in the U.S., and exported for very little in return. Furthermore, countries have varying levels of care based on the countries budget.

When the rich people in europe get sick, they go to the U.S..


That's similar to my experience in Thailand. Everyone in my family has had one or more hospital stays for illness, surgery or injury. Prices for common procedures are posted. After initial evaluation there is a discussion about what the estimated total cost will be.

I would never again want to have medical treatment in the USA.


We could have said no and gone elsewhere if we wanted, since the patient at least was relatively stable and we knew what was wrong.

Next question, if the patient did go elsewhere, would they get to keep all the test results/would the hospital share the test results with the new facility? Or would the new place have to rerun all those tests?


> would they get to keep all the test results

Huh, is that a thing in the US? I understand the old hospital might not automatically giving them to you or the new one rerunning them anyway for practical reasons. But if you've payed for the tests, I'd expect you to own the results...


I believe so. We specifically asked if we could take our results with us, although I didn’t specifically ask what would happen if we rejected further treatment. I think it would have been fine, though, and likely they would have charged us at least a small amount (maybe around $100 USD).

Would you prefer the Singaporean norm (clearly posted prices) to the Canadian/European one (free at the point of use)?


There is no single "European" model.


True. In fact it is worth noting that a large portion of the ACA/Obamacare model was based upon Swiss healthcare (specifically the individual mandate in particular) due to its heavy private market presence.

First line in Wikipedia (https://en.wikipedia.org/wiki/Healthcare_in_Switzerland) There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country).

The difference being their version of the individual mandate was not struck down or watered down to becoming a 'penalty'. Instead it was like what we do with auto insurance.


Neither is it "free", at least not in Germany. It gets charged to your insurer.


Personally, yes. Like many posters here I am an Engineer not in the medical field, so take my opinion with a grain (read: mound) of salt.

Most "free" healthcare systems have either (1) horrible quality of service or (2) impossibly long waits unless your life is in danger or close to it. The latter is a systemic issue I've noticed in that healthcare, regardless of pricing or structure, does not aim to foster optimal health, but merely to prevent mortality - so if you go with a 'minor' issue such as recurring headaches or chronic fatigue, it will be dismissed entirely.

I don't have the right answer here and am all for people having affordable options from 'free, wait 3 months' to '20K, full service now', but once again, personally speaking, I'm not rich enough for 'free' things. I'd rather pay and know exactly what (and in this case, much more importantly, when) I'm getting. And from what I've noticed, my personal beliefs that people should strive for optimal health rather than mere preservation of life, is a popular opinion deemed 'unrealistic' by experts.


As a soon-to-be Canadian who has only experienced the US and Canadian systems, up here the quality of service isn't horrible and the waits for service tend to be shorter than they are in the US - but they are based on need rather than wealth. So someone in discomfort but no danger will end up waiting longer in Canada then if they were rich and lived in the US, but my relative with cancer was seen to promptly due to a high chance of complications if surgery had been delayed.

So I'm not sure what constitutes "most free healthcare systems" but Canada is apparently different from "most"


If you are rich and live in Canada, you can cross the border and pay out of pocket to receive treatment in the United States. I wouldn’t be surprised if Taiwan (the only other country with a Canada-style one-tier single-payer system) has a similar relationship with Singapore. Britain also has the ability to pay out of pocket for private practice care as an alternative to the NHS.


Re: quality vs wait period trade off.

We generally call this the 'Iron Triangle' in healthcare policy/management. You basically get a pick at most two out of (1) access, (2) quality, (3) cost.

As to your general sentiment healthcare is a bit 'one size fits all' when in terms of insurance/reimbursement solutions. Note that the needs of the aforementioned triangle are weighted differently based on acuity of care. More generalized simple/low acuity care we are happy to get low cost and ready access as our best solutions (e.g. minute clinics, online/virtual care/telemedicine for getting a vaccine or pinkeye/localized infection without complication).

Meanwhile ER representing the other spectrum we instead have greater need for higher quality and access. You must get to an ER ASAP and get stabilized.

Chronic care quality solutions with long term cost-effectiveness are what are needed. Access to a specialist for longer term condition management (or episode or care like a cancer diagnosis).

Similarly more procedures are becoming outpatient, or recovery at home, or at dialysis centers, or at skilled nursing facilities ... you get the point.

I argue the problem is that the insurers have not adequately fragmented the insurance market/reimbursement model. Healthcare is changing in how it is delivered and insurers are not keeping up with it when it comes to modeling their payouts. For example why does being in-network matter for low cost care at outpatient facilities? The added 'negotiation' of being in a specific network doesn't add much value. One size fits all doesn't work with the modern spectrum of care.


What are prices like? I suspect they are much lower than the equivalents in the U.S. Thesis: transparent pricing tends to keep prices down.


Playing the devil's advocate for a sec here. But If you paid out of pocket and later got reimbursed by the insurance company, I think, you would have to deal with the insurance company later. The system in the US is quite different and although broken it can be fixed by just fairer price comparison mandated by law.


The only way that will work is if the insurance companies have to pay the posted prices, which I advocate as well.


It is if you're a pet. This is exactly how my veterinary visits go.


For someone who worked on price transparency in 2013 - I was personally affected with surprise billing - and spent long hours working on a price discovery / transparency tool called pricepain.com, this (first step of an) anti cartel measure brings tears of joy. While it won’t solve all issues at once, shining some light into the medical billing mess can only be a good thing, allow market forces to enter the picture somewhat. It’s rather sad, that it didn’t come from the industry itself - but I guess that speaks volumes already. Florida faced a dilemma with their incredibly broken public school system many decades ago and was stuck in a political gridlock as no party agreed on any measure the other would propose to improve the situation. Finally, the only item both parties did agree on, was to grade schools. Just a single simple letter, a search for more light. The result of a little bit more transparency caused a chain reaction of consequences leading to higher quality of service overall. I hope that similarly this move will spark a quality/performance re-orientation and help create more Surgery Centers of Oklahoma. It’s high time.


Something I worry about, and that maybe you can help shed some light on, is what the ramifications of such a move would be.

You mentioned the grading of schools leading to higher quality. Do we know if any metric suffered as a result? One guess I have is that teachers started teaching for the test rather than for the foundation.

Take that same question and apply it back to the issue of hospital cost. If there's more transparency, the obvious conclusion is that there will be increased competition and an overall lowering of costs for patients. Does that come at the cost of quality of care? My gut says no, but my brain says that hospital administrators are incredibly talented at cutting costs. Maybe we have other safeguards such as HCAHPS to prevent the worsening of quality.

And as my own comment on this situation - how does this move fit into the insurance realm? My understanding is that hospitals will display the overinflated prices, but not the individual insurance negotiated prices. So how does this increased 'transparency' help?


> You mentioned the grading of schools leading to higher quality. Do we know if any metric suffered as a result?

We don't know. Something might have suffered but if you're not measuring a metric, you can't really know anything about it. That was the reality of the educational system--very little measurement of anything--and hence the baseline of agreement (not just in Florida but in many states) was simply: let's start measuring.

> One guess I have is that teachers started teaching for the test rather than for the foundation.

This is a good guess, and some teachers and parents definitely agree with you. But the reality is that (again) unless you are carefully measuring a metric, you don't know what is really happening. Collecting a few anecdotes and opinions does not necessarily result in good data.

It's also possible that in the absence of performance metrics, some teachers managed their work to maximize throughput and minimize complaints--by passing students through to the next grade whether or not they were ready. This is also supported by anecdotes, like colleges and employers reporting a decline in student readiness.


I suspect that with teachers teaching to a test, it improves bad teachers and holds good teachers back a little.


It accomplishes little. The tests are a subset of the things the students should have been learning anyway. The idea was that by measuring performance teaching could be improved where needed. The actual result was that the "help" given to classes with bad scores has been to overtrain some tiny neural nets to respond to very specific stimuli without teaching them anything beyond the specifically measured behavior. Even the students that pass often haven't mastered the material. They just can take the test. We opted to replace accountability with process and reaped the usual results.


Either way, the result is that the students learn to take the test well and might not learn much if anything else.

...and Florida still is a bad place to get a public education.


I'd be happier to see regulated business practices. While I agree that the prices are a problem, I've felt more pain from bills that keep coming in for more than a year after a major event. And when I go to complain, they say that someone made a mistake, the insurance took a long time to respond, or some other excuse. Give me a final bill with all charges within 30 days, then 30 more days to resolve any issues with that bill, and then let the billing end so we can move on with our financial lives without wondering if one more bill is going to show up next week, tied to my credit record.


One thing that troubles me, is the hospital near me does the same thing, but "consoladates the bill". This literally is just a never ending fee that increases and they never list for what.

Every single month I call and they give me the run-around. After 6 months of this, I have yet to pay the full bill until they mail me an itemized list and without fail it's wrong. I contact them, they remove two or three charges, I ask them to mail me the updated one. They do, then next month I receive a bill for those proceedures they removed the last time.

Its to the point every month my bill now goes from $0 to ~$800, then back to $0 by the end of the month. Unfortunately, they now called and threaten the ~$800 "over due bill" to collection's. Luckily, I've recorded and documented everything, so I got it removed (again).

However, I'm just waiting for this to go to collection's at some point, even though I owe zero at the end of every month. I'm 90% sure this is a bug in their system, but I can't seem to get around it.

Having worked for a medical billing office, I hate to say it, but this is the norm. The billing office is often not officially the hospital or medical practice. Although we got all the records, we never really interacted and it was just files on a computer. I used to do write-offs, which was basically taking $10m a day and just clicking "don't need to pay". Usually it was dead people, poor, etc. At least that part of the job seemed somewhat nice.


I currently use hospital billing as an example when explaining the halting problem. You’re never sure if you’ve paid off an incident or if another bill will show up in a few months...


Before we were married my wife had an MRI. Having not met her deductible they sent her a bill for 1.5k. Not ideal but we were able to afford it and paid the bill. 364 days later we received another bill for roughly the same. We thought there was an error. After months of back and forth, even after they had told us for 2months that “they took care of it and we would not be charged” we ended up having to pay another $500. This whole process was beyond infuriating.

The other bill apparently came from the Dr who read the MRI. The fun part was we were never contacted by that Dr about the results. She eventually left the hospital and she canceled our follow up appointment.


The part I love is when the insurance company points the fingers at the clinic, and clinic points fingers at insurance for how long the whole thing takes, meanwhile I get sent to collections.

/now I pay a few dollars (no matter if I owe something or if they owe me) near the end of the 90 days those two companies have to figure out how much I owe so I don't have to deal with collections.


Think that a provider gets that billing cycle as well. Every patient that has insurance means the provider needs to collect from 2 different agencies: through the credit card in a copay and through the insurance, that fights the price.


I've heard of why the insurance companies usually take a while, something to do with HIPAA and some insurance companies being bought out, so now they have to forward information back and forth, all whilst remaining compliant. At least something along those lines is what someone from HR at my company (not related to the medical industry) was telling us one time. I wasn't able to find a good article on it though sadly.


It is regulations that have given us the current obtuse system.

When you give agency to someone so they can "fix the problem" you inevitably create a means for wealthy special interests to grasp control.


This won't help consumers. The prices (both charges and what Medicare pays) are already effectively public: https://data.cms.gov/Medicare-Physician-Supplier/Medicare-Pr...

The problem, as some other comments point out, is that they're way too complicated. The link I posted, for example, is just the provider charges. A hospital visit typically has a facility claim and at least one provider claim. Depending on the type of service received and the agreement between insurance and facility, the facility fees can be billed a variety of ways (diagnosis related groups, ambulatory payment classifications, or HCPCS). Each provider that sees you or performs labs, x-rays, etc can bill separately, and each could have a separate or no contract with your insurance. The latter is how surprise 'out of network' bills happen.

It's a total mess and hopelessly complex for the average consumer.


I shared this experience before on HN, but I once cut my leg quite severely playing ice hockey. Ended up at the ER dripping blood everywhere. I went to the desk and asked if they took my insurance. Said I was only interested in treatment if my insurance would cover it. I was assured it was fine.

Naturally the doctor assigned to me did not take my insurance...

I got out of the out-of-network billing after hours of phone calls and lots of unkind words. But man was it just a terrible experience. And with insurance coming from work, it’s not like I could change providers. And with one hospital close to my house I didn’t have lots of options in an emergency. Nor would I expect any other hospital to treat me differently.

My dad is a nurse and I grew up wandering hospitals. He complained as far back as the 80s that insurance was killing medicine. I didn’t understand it as a kid, but I see more what he was getting at as an adult.


Just out of curiosity: have you tried calling your insurance to ask them where you should go?

I haven't either, and have generally gone by your route of asking the hospital whether it will be insured, but I'd imagine calling insurance (if a feasible option?) would provide a lower rate of error.


The patient shouldn't have to call the insurance provider to see where it is accepted. This is adding to the problem. Do you have insurance, yes or no? Should be a good he only question not add-ons like, what provider, etc. It's stupid as hell that certain doctors are in network at a hospital while others are out of network, at the same damn facility. Ask me how I know this. American Healthcare insurance and billing is beyond messed up and needs to be fixed.


> The patient shouldn't have to call the insurance provider to see where it is accepted

But this is actually the one that provides the service. You dont call the music band to ask about the prices ticketek charges. You should and can ask about the price without insurance and you might get an answer (though you wont like it).


See other comments in this thread about where that question gets you. My experience has not been any different. IE, the answer ranges from "I can't tell you until the procedure is done", to exorbitant quotes. Of course I don't like those answers, who does?


You can find someone that knows the prices. Small practices will know, and in hospitals I'd try someone from staff, not doctors because they are overworked with patient loads and are shielded from the admin burden.

What makes the expectation unreasonable is when you don't know what you will need. Surgery is a great example of that: what if there is a complication? What if a specialist is required, etc etc.


The collecting system is way too complicated for a provider to know. Nobody can reasonable assure you of that, the same way an accountant cant assure you you are compliant on all IRS codes, or even a doctor can assure you you will be healthy if you do a treatment.

But think what happens when you have a patient with insurance, bleeding right in front of you: would you turn them away because of this lack of assurance? its an unreasonable ask of a human being.

Insurance copmanies are the Ticketek of the health industry: they take the bad rep for the ones reaping the benefits.


As I noted below ($25 vs. $1400 for my sore shoulder), the range of ways providers can "code" what they charge you for is not sane. And how my inpatient bill in a different situation reached ~$45,000 was clearly because the hospital knew how to pad the bill.


And in fact I'd say medical coding is a boarder line predatory practice. There are a number of companies that specialize in padding / inflating medical codes against insurance companies for hospitals (or fighting them etc). It is just another inefficiency in the current system costing everyone more money.


A friend's brother owned a construction and landscape company. One of their key philosophies was "You have to know how to write a bill." A wide range of equipment types, each with different hourly rates, can be used on any one job. Different procedures can be used. Figuring out the combinations that create the greatest "defensible" profit was a widely acknowledged goal of most companies in the space. I am also aware of training companies that do something similar.

It's a common business mindset, unfortunately.


> It's a total mess and hopelessly complex for the average consumer.

Sounds like something the people on this forum can help improve.


Sounds like something the people on this forum can help improve.

A lot of the problems average consumers face are political/social and not technical (technical problems associated with these issues were solved decades ago). For example, it takes 10 days for my bank to send funds from U.S to my home country. Why 10 days? I have no idea. What I do know is 10 days is extremely unreasonable at the end of 2018.

I filled a form and put "none" for "any visible marks like scars, tattoo etc?" question, because I honestly have none. The form got rejected, now I have to "creatively" answer this question.

When my dad was in the hospital, I got so many bills - I had a lot of trouble looking through those and locating errors (we were charged extra and the only way to find those was to painstakingly go through the bills line by line). I had no energy or interest to do it (when my dad was in the ICU) - every single thing was complex, needlessly so, and was frustrating to the point of tears.

And then comes insurance - ever tried post processing a claim? Wouldn't wish it on my enemy.

There are hundreds and hundreds of examples like these - hospitals, courts/police, banks (even the private ones), airports, any government office in general ... it seems as if they relish in wasting average person's time and money. No amount of software/ML/AI etc can fix these, until the mindset is changed for good.

A large group of people owe their careers and salaries to these inefficiencies, they won't give it up without a serious fight. For example, filing taxes in US - there is no way H&R block, turbo tax etc will go down without a fight, it is just not in their interest to have a simpler tax code.


It makes me depressed to have to fill out some form with information the government already has just to do my taxes. Just send me my return and I can dispute it if I don't like the result.

I guess there is political pressure to make the process as annoying as possible, and not just from tax services corporations.


It's not a technological problem but a political one: the obfuscatory pricing is deliberate.

Maybe you could have "fighting hospital billing as a service", but that's definitely going to need a chunk of human labour on top of whatever AI assistance you apply.


I agree that the problem is political.

While it might be nice in the short term to see some technological approaches to address the mess, the solution is ALSO political, NOT technological.

Making the information public, however obfuscated, will enable journalists and activists to systematically expose this problem for what it is and that's the first step towards fixing it.

The next thing that will happen is that many more people will be able to win massive lawsuits which is the only recourse the healthcare/insurance industrial complex understands.


Is there any way this could be represented via interactive graph? We were able to tame much complex stuff than deliberate obfuscation by people not aware what tech can do.

I guess there is not enough incentive ($$) to solve this problem.


The $$ is being made by the hospitals

See https://www.vox.com/health-care/2018/12/18/18134825/emergenc... to start digging into the mess


But technology can help patients unite against hospitals... Just like Yelp crowdsources the restaurant experience, or Glassdoor crowdsources salaries,and anotherss could collect crowdsourced medical bills and predict prices for procedures.


So, somehow technology can help educate ~300 million people about insurance, procedure costs, payments, and also provide medical education to those 300 million people so that they can wrap their head around the necessary medical lingo?


In a way it's like if Apple was advertising the price of its individual electronic components rather than the all-in price.


It's far worse than that. It's like if Apple didn't have a price for an iPhone, but instead at the register it scanned the package and looked at which factories each part came from and which assembly-line workers in those factories worked on those specific parts, and which mines the minerals came from, etc. and then charged a different line item for every one of those factors.

Sure, the average cost is $1000. But yours might be $5000.


> It's a total mess and hopelessly complex for the average consumer.

But not for insurance companies; it's in their interest to compare hospitals and get the best care for the lowest price.

I for one hope this will trigger competition. On the other hand, it'll probably end up shafting the personnel instead of the ridiculous profit margins.


The idea of effective competition in emergency services has always struck me as fanciful.

The benefit that competition provides to incentivize lower prices and better services is a consumer's ability to easily deny someone their business and go elsewhere.

What would this look like here?

Would one be in the back of an ambulance doing price shopping on a tablet as they are fighting some terrible injury?

Perhaps tie in different billing departments in a conference call as they bid over who will do the critically urgent surgery as the patient slides in and out of consciousness?

Maybe decide to have a heart attack during a winter sale special or reach into their dresser to get a coupon out as they collapse to the floor?

Or would someone be placed on a transportable life support system as they get ferried across a city deal hunting by having different procedures at different institutions, expecting them to talk to each other and string together piecemeal lab results for a coherent diagnosis?

Maybe someone would do the work beforehand, search all the popular ailments and their procedures and then do price shopping in good health and prepare an execution plan if they fall ill?

Maybe there's a non-absurd example, but I honestly can't think of it. The competition mechanism seems to be a completely unrealistic application.


Even if you limit competition among hospitals to non-emergency procedures, it would still be enormously beneficial.

But even with emergency procedures I think you could still have effective competition based on outcomes and price. Here's an article suggesting that in some cases a poor quality hospital will triple your chance of death compared to a good hospital [0]. With more data, I could imagine a study that says, "Hospital B is so much worse for treating heart attacks than Hospital A that it is equivalent to delaying treatment by 20-25 minutes". Paramedics treating a heart attack victim would therefore have a fairly simple calculation: What is the difference between estimated time taken to reach Hospital A and estimated time taken to reach Hospital B? If more than 25 minutes you choose hospital B, if less than 20 minutes you choose Hospital A, and if between 20 and 25 minutes you choose whichever hospital historically charges the least for heart attack treatment.

[0] http://www.nytimes.com/2016/12/14/business/hospitals-death-r...


Ambulance staff are incentivized by pretty nurses and free food/snacks. Ask any paramedic in a city with enough choice of hospitals and they'll tell you.

What is the best answer to the "emergency care competition" that you've found?

And what proportion of medical spending is on emergency vs. not?


Even in non-emergency care, perfect competition requires perfect knowledge (the consumer to know medical knowledge), perfect information (knowing the exact quality of care from all competitors beforehand), rational buyers (having no preexisting biases based on irrational cognition), no barriers to entry or exit (ie, being able to switch hospitals mid stream), no network effect (the previous state...eg who does the lab work, shouldn't have an outsize influence on the subsequent, eg who does the diagnosis... See dollar auction for an extreme example https://en.m.wikipedia.org/wiki/Dollar_auction) and a variety of other fairly unachievable factors which do not apply here.

It's not a good model to structure the allocation in this particular instance, too many conditions are nearly impossible to satisfy. It's not a sensible way to design this market.


Perfect competition? There is no such thing in practice. Also potentially a way to outsource this to a group with better knowledge.

Dentistry is a good example of competitive service, eye care is as well. And negotiation is normal.

You're moving the goal posts in the right direction, but to the edge.


Plenty of things are pretty close to perfect competition

Grocery stores, sandwich shops, coffee houses, clothing stores, coin laundromats, circuit design, postal carriers, kitchen utensils and serving equipment, rental cars, housekeeping things like brooms and dustpans, bouquets and flowers, nuts bolts and fasteners, airlines...

Essentially anything where the brands are fairly indistinguishable and you have a hard time separating them. That's competition working.

Eyeglasses are probably one of the closest in medical. Common medicines like lactase, dextromethorphan and acetaminophen also score high.


Eyeglasses, at least, are a monopoly controlled by one company, Luxottica. See https://www.forbes.com/sites/anaswanson/2014/09/10/meet-the-...


I get mine at one of the myriad of online retailers, who seem to be outside the clutches of that corporation. There's no restrictions duties or tariffs on importing eyewear in the US and the prescription sheets are technical and specific enough to be fairly language independent.

The internet disrupts consumer by consumer and product by product, not industry by industry.

Going to a brick and mortar certainly appears cost prohibitive once you get used to paying $10 for stylish fitted pairs of prescription glasses.


Airlines are definitely not an example of perfect competition. They are the number one textbook example of oligopolistic competition leading to price discrimination. A given route between two cities only has so many airlines competing. They just have a tough time surviving because airports are monopolies (except in some major metros where there is limited competition), thus can capture most of the airlines' profits.


Good goals, but we know the current market structure is light years away from perfect.

Definitely a situation where any partial progress toward clarity and openness is a big step in the right direction. The potential for cascading changes in business practices and further reveals of all the private deals and hidden costs makes it an even better value in the future.


>>What is the best answer to the "emergency care competition" that you've found?

Pay what the insurance or medicare pays, plus a capped xx% because they got a volume discount. By law hospitals have to stabilize you, can't let you die, money or no money. (I know they have been cases of trying to dump patients but...)

So you saved me, but how did you come up with the $455,000 bill? We entered into a contract without prices, so the prices should be customary. 5-10X what insurance pays isn't fair.


I meant the best answer to the "there is no competition in emergency care" objection.

Is there a current good answer to a consumer having the ability to competitively (without too much work) receive emergency care?


You could do limited supply side bidding and some of that already happens, but proximity to care matters so much that I think structuring it like all the other emergency services (such as police and fire) is probably the right way to go. Urgency is the only maximizing function.


Public utility, no competition for emergency given how it works. Nose job or breast implants are another thing. Emergency prices linked to Medicare.

But then, I can imagine them charging, say, $3800 to stabilize you with whatever surgery (there goes the urgency) and start billing you normally for the rest of the care. They'll make it back and then some.


I'm not sure this is the case. Since medical insurance companies are heavily regulated on margins, their primary way of making money is investing the "pool" that's used to pay out claims. The size of this pool is determined by actuaries, so it can't be increased arbitrarily. But it grows in two ways: more patients, or more required reserve per-patient. In this way, insurance companies actually benefit from higher hospital prices.


Health insurance has ridicolous margins? Whats your source?


My guess is that eventually the govt will step in and start regulating prices if providers don’t.

One interesting idea (not well thought out at all) would say that all prices need to be +\- 50% of what Medicare pays.

Medicare pays $20,000 for stent placement? Great! You can charge whatever you want up to $30,000.

A lot of effort goes into setting Medicare rates (and they are based on self reported costs across the country), so forcing providers to be in the ballpark of those might help.

It wouldn’t solve the issue, but it would eliminate those ridiculous “why do you charge $10,000 for an MRI when the clinic down the street charges $1,000?”.


> all prices need to be +\- 50% of what Medicare pays.

This is actually close to what happens with private insurers- they negotiate with a hospital to pay n-times what Medicare pays for some set of treatments.

So why does Medicare pay the least? Because they have the most patients covered of any insurance network in the US. That's a hell of a bargaining factor. More patients = cheaper prices.

The logical conclusion is to then have Medicare for all. That'll regulate all prices to be exactly what Medicare pays!


That still doesn't explain how prices of medical services in many other countries turn out several order of magnitudes smaller than commonly encountered prices in the US.


I've discussed this before, but I think there's quite a bit of funny money in hospital bills -- a 10k bill rarely actually materializes in 10k transferred across all parties involved.

Doctors bill $10k to your insurance, the insurance decides its too much, lawyers are on-hire to negotiate and take a 30% cut of the outcome, and finally 2k is paid out; the absurd bill naturally accounts for the absurd process, and I don't think anyone except the consumer ever expects 10k to really be 10k. And ofc, the insured consumer only ever pays $500 of it from his deductible.

This was basically Shkreli's defense as well -- the insured patient doesn't pay anything close to the bill given; and I'm pretty sure, neither does the insurance. If you want to raise the price be $10, you add $1000 to the bill.


This type of billing practice causes a mess of winners and losers, essentially unless your insurer has good pricing with wherever you end up getting treatment (often not a choice you get to make in an emergency), you can end up holding the bag for the cash price, usually half of the $10k number you mention. Quite ridiculous when other insurers are paying less than half that price, smells of a scam.


My conspiracy theory is it was designed this way over time so that people “needed” insurance (before it was required).


Not too much of a conspiracy theory.

What’s ironic (?) is that by mismanaging a scheme to get everyone on private insurance they’re really working towards socialized insurance. Which good or bad, there is no going away from once you have it.


Agreed, providers are not as willing to negotiate with you as they are with insurance companies. Probably because they've already negotiated...

Just go all cash with an HSA.


I'd be curious to know how much of that is caused by malpractice insurance. I mean if hospitals were overcharging so much, then surely we should see lines of rolls royce in the hospital parking lot. Doctors are well paid in the US but they are typically not rich.


> Doctors are well paid in the US but they are typically not rich.

What doctors do you know? My friends who are just getting out of residency and such are making a few hundred thousand a year. My college roommate’s father was an anesthesiologist making $800k/year.

Just because they don’t draw attention to themselves with ostentatious vehicles doesn’t mean they couldn’t afford to (the anesthesiologist only had a Porsche for each of his kids).


The first result on google (that I don't particularly vouch for) seems more in line with what I would expect:

https://www.sokanu.com/careers/doctor/salary/

So between $200k-400k depending on seniority and speciality. It's not really outrageous compared to other, highly educated professions.


Not outrageous, but that puts all of them in the top 4% of US incomes, and after a decade or two of that basically all should be counting a few million in assets. That’s rich and far, far beyond average in this country let alone the world. Compare to other first world nations where doctors typically make half that (or less), but probably aren’t saddled with the unreasonable educational expenses.


As I said, I don’t think they’re actually charging that much — negotiation with insurance is expected, with like 80% reductiond to initial price. They’re still paid very well ofc, but I think complaining about the high initial bills itself is a red herring, because no one involved expects that amount to actually materialize


HDHPs are becoming extremely common. A $500 deductible would be amazing. Deductibles in the thousands of dollars are more common - mine is on the higher end, $6600, while still costing more than 20k a year.


Are the prices that Medicare pay orders of magnitude different? ISTR that Medicare and the VA both pay about $10k per patient per year, which I think is comparable with the NHS. No sources as this is half-remembered.


People on Medicare are over 65 and people in the VA have been in the military. Both of those groups of people are going to have much higher medical needs than the general population.


NHS spending is £2892 per person/year, that's quite a bit lower.



Huh, that's much lower than I thought.


There's a bit of complication because we're comparing one system with not much insurance with a different system that has a lot of insurance.

Here's a nice run through of the numbers.

https://www.bbc.co.uk/news/uk-42950587


We would also need to know the average number of visits per patient before this data means anything otherwise it's just data without context or meaning.


US health spending in aggregate is between 2-3% more than comparable European countries. Life expectancy is several years lower.


Because doctors in the US can easily make $300k+.


No. Medicare pays the least because the don’t negotiate. They just set prices. As a hospital/doctor you can choose to accept Medicare patients or not. Most providers lose money on Medicare patients, or so the like to say.


What do they mean by "lose money"?

Even if I turn up at a private hospital here in Norway, I pay nowhere near what you would pay in the US. Which tells me that either hospitals are run extremely inefficiently in the US (orders of magnitude worse than here) or there are layers of pretty substantial profit margins.

I may be a bit peculiar, but I think a healthcare sector that is set up to mainly benefit execs and shareholders is a bit immoral.


Medicare reimbursements are below cost of care.

If all insurance lowered to Medicare reimbursements, you will reduce supply.


That’s what most providers claim. In my experience (healthcare Corp finance), it’s typically closer to breaking even on Medicare. Especially if you cut out some fluff/unnecessary spending companies like to engage in. I’ve worked with Medicare and they actually try to do a bottoms up, zero based, pricing to determine what something should cost. So when a hospital is built by some award winning architect and has fountains and statues etc. Medicare doesn’t cover that (donors often do in the hospital example, but not other lines of services). I often have to explain to C suites that Medicare should be seen as a high volume that basically helps break even thus covers your fixed costs in entirety and making commercial patients all the more profitable.

That said, every branch of healthcare works different and could be upside down from this where they make a ton on Medicare but not commercial


Considering private pays almost 200% what medicare pays, I doubt it.

Its more like how airlines work: they make money on first class, and coach is something that fills the plane to cover some costs. If planes were made mandatory to only have coach, they would go bankrupt.


At least from what I know, its accepted medicare is below cost. I cant attest for padding or number fudging, but at least in primary care medicare pays crap and below physician salaries.


I was referring to private healthcare without reimbursements or insurance. And mind you: Norway has a pretty high cost of living so it isn't like this is a low cost country.

Which suggests to me that prices do not reflect actual cost, but rather inflated profit margins.


> Which suggests to me that prices do not reflect actual cost, but rather inflated profit margins.

There are lots of healthcare companies that are public. Healthcare insurance companies are amongst the lowest earnings of any insurance, contrary to the argumentational of Bernie Sanders. Also, one of the biggest health insurance companies, blue cross, is a non-profit.

Furthermore, 60% of hospitals are non-profit. And hospitals are 30% of the national healthcare spending.

If we are theorizing at random on what changes could impact the cost-effectiveness of healthcare, it is the increase of profits, not the decrease, that would be a more significant change.


So how do you explain that getting treated at private hospitals (on your own dime) in Norway is cheaper than in the US?

That private healthcare in the us is heavily and negatively affected by regulation.

US has.. - a very low doc/population count, due to the artificial constraints of medical licensing and immigration law.

- a draconian FDA process for drugs and an unreasonable patent application to drugs.

- An incredibly distortive public service implementation (Medicare) that provokes cost-shifting (by paying below cost), that creates heavy admin burden (fee-for-service), and that overpays specialties and punishes primary care (fix reimbursement fees in multiples for specialties, giving a very low primary care doc count)

- An incredibly distortive tax credit for the wealthier to spend on healthcare (the richer you are, the more tax effective it is to get better insurance through your employer)

- A free-market abolishing regulation requirement: tying healthcare provider to employer.


Wouldn’t it make more sense to properly separate private and public? If hospitals can be either Medicare-only or no-Medicare (using Medicare as the name of a future broad/universal system much larger than Medicare/aid is today) then hospitals would chose to be Medicare in proportion to how many are covered. If everyone (including those who chose a private insurance) pays a full insurance premium for the public system on their taxes, the private insurers’ patient lists would shrink very quickly, and so would the number of hospitals that could survive by providing treatment to those patients. So looking from outside it looks like “hospital prices” is just another one of the problems that would be solved by a tax funded public universal healthcare insurance?

Example (Sweden): I pay a full public insurance through taxes, and I have a private insurance via my employer that lets me cut some waiting times for certain procedures from 90 to 14 days. It’s an expensive way for my employer to make sure I’d be back to work quicker than I would otherwise be. Obviously, this is a luxury few use or need so the number of hospitals that provide this care is extremely limited (a few percent).


If you have public hospitals that are tax funded and private hospitals, you will see that private hospitals will only provide profitable services (cardian, neuro, etc) and give all loss patients to public hospitals (psychiatry, managed care, etc). Public hospitals will have a unreasonable burden of high-cost patients.


I think you misunderstood: anyone who uses private would do so while also paying for a full public health insurance. That is, the public system is fully funded regardless of whether anyone wants to operate private hospitals.


Ah, that would make healthcare a lot more expensive, making people pay twice for the same service.


Yes - it makes private insurance an added luxury product. This is normally how it works where there is a publicly funded universal system. On the other hand the public insurance covers many expensive things very well (e.g cancer treatment) so the private insurance is for things like getting a knee surgery without waiting time where the public system can have 90 days waiting time. Someone like an athlete wouldn’t want to wait that long but for most people it’s acceptable if it keeps premiums (taxes) lower.

The “paying twice for the same thing” is a feature, not a bug. Most people wouldn’t do that of course, meaning they would simply get rid of their private insurance.


It makes it inefficient in economic terms. I think you are attempting to frame it in terms of cost-shifting: making the "rich" pay for "the poor" by paying twice.

But when the public hospital is 10 miles away, and the private hospital is 1 mile away, paying twice effectively lowers the access of care to the people that can't afford to pay twice.

And then, proximity to public hospitals would be so valuable, that housing prices would icnrease close to the best public hospitals, and the richer will again take profit of it, just like it happens with zone-dependent schools.


Doesn't that type of inefficiency already exist when a patient may need (or want) to go to a "network hospital", when there are multiple competing networks instead of one enormous one (that has say 95% of the "market")?

> paying twice effectively lowers the access of care to the people that can't afford to pay twice

My private insurance that kicks in if I e.g. need a knee surgery with 14 days wait instead of 90, will often require me to fly to a different city, likely even a different country, to get the procedure performed at a specialist private clinic. This care is something completely different to the regular care I need day-to-day for a child delivery, cancer treatment, appendectomy or whatever. As there is so very little overlap I'm also not paying twice. There isn't a private insurer that will offer me cancer treatment, child delivery etc.

They don't exist because who would want to pay twice for that?


> Doesn't that type of inefficiency already exist when a patient may need (or want) to go to a "network hospital", when there are multiple competing networks instead of one enormous one (that has say 95% of the "market")?

Not really, because all the insurers typically insure all hospitals. By having multiple insurance companies, hospitals get bargaining power and lower what insurance can ask from them. If you had only one insurance, like the state, you have 3 possible solutions: its the same, it pays more than the competing system (overly generous and thus worse for the tax payer), it pays less (uses monopoly market power and reduces hospital size/supply)

Hospitals and insurance companies are in a bargaining fight constantly, and if you look at the numbers, hospitals have won. However, hospitals are 60%+ non-profit (60% non profit, 20% public, 20% profit hospitals), so its not so clear you want hospitals to lose. Its really messy.

> My private insurance that kicks in if I e.g. need a knee surgery with 14 days wait instead of 90, will often require me to fly to a different city, likely even a different country, to get the procedure performed at a specialist private clinic. This care is something completely different to the regular care I need day-to-day for a child delivery, cancer treatment, appendectomy or whatever. As there is so very little overlap I'm also not paying twice. There isn't a private insurer that will offer me cancer treatment, child delivery etc.

The main benefit of having a single insurance company, or single payer system, is that you dont have to spend so much moeny on administrative costs. If you start getting into the rabbit hole of what will be public or private, at what cost and quality, i suspect the gains from the administrative relief will fade. Economically, maybe the best thing about having a public/private system would be that the public system is dirt cheap and effective, while the private one is simply more expensive. Thus there is some component of redistribution, but also some market forces. I think hybrid beats full state owned (I accept my own ideological bias and maybe hybrid beats fully private, though I believe it wouldnt).

> They don't exist because who would want to pay twice for that?

As an example of this, I can speak of Argentina. Argentina has had a diminishing public expenditure of public funds to public health. It has a very decaying public health system, and a thriving private one. The private one does have price controls, but not too much in effective terms: they biggest cost threat is probably that patients could choose to not have private insurance and just go to a public hospital. The reality is however crude: some public health services are of terrible quality. But its a trade-off: poor people dont pay and receive quite the tax benefit as a whole. Private is thriving and has very good quality metrics at reasonable prices. So yes, you can have a system with "double paying" that is definitely stable.


Some insurers benchmark Medicare rates for some procedures. It certainly isn’t the majority of rates, those tend to be percent of charges.

And no, Medicare doesn’t have the lowest rates (Medicaid does). The rates aren’t low due to negotiation (hah!), it’s the gov’t basically saying “here is what we pay, take it or leave it”.


Except republicans and bush passed a law a decade ago saying the government can't negotiate drug prices for Medicare. It's beyond stupid and the main reason you see so many niche drugs go up 50x in price overnight lately. The companies have figured out they can exploit that law this way.


So if you eliminated medicare and put all those patients into private insurance, they would all lower prices?


If you look at healthcare vs GDP, the US is way above the line compared to comparable countries. https://www.healthsystemtracker.org/chart-collection/health-...

I think scaling the average costs from other countries accounting for GDP would be a good way to set the rates.


If you look at the actual household income in various countries, as opposed to the GDP, which doesn't always track household income as well for many OECD countries, it turns out that the US has pretty much the healthcare consumption expected for its average household income: https://randomcriticalanalysis.com/2018/11/19/why-everything.... Based on this analysis, I think the primary issue with US healthcare is the fact that people, especially with bad insurance, can be wiped out due to medical debt. On the other hand, even countries that have tried to control their healthcare costs have generally failed to make much impact.

In all OECD countries, unfortunately, healthcare spending doesn't seem to be especially correlated with increased lifespace.


I'm not so sure average household income would be all that useful when income inequality is high. You would have to slice and dice those numbers a bit more to make them even vaguely representative of reality.

Besides, you have to factor in living costs.

I've looked into living cost a few times when considering working in the Bay Area and I realized that while my income would easily double, my living costs would increase a more than just a factor of two. I would have to accept a lower standard of living than I enjoy now.

I think the only way to really deal with healthcare cost is to look at whether or not we think it is a good idea that there is a huge profit margin. For patient outcomes and for society as a whole.


> On the other hand, even countries that have tried to control their healthcare costs have generally failed to make much impact.

Because healthcare is an ever expanding, ever innovating industry with infinite scope. For countries with universal healthcare this is painfully obvious. What once was a service in the 1950s to perform what now would be considered very rudimentary procedures and proscribe < 1% of contemporary drugs, now do space age procedures as if routine and treatment plans that took decades of international cooperation to develop.

> In all OECD countries, unfortunately, healthcare spending doesn't seem to be especially correlated with increased lifespace.

Diseases of plenty now represent greater harm in most of the developed world than do ailments of scarcity.


Please stop using average. Median is a much better measure.


It’s really not in this context. The median household vis-a-vis income isn’t necessarily the median household vis-a-vis health consumption. More generally, health spending is massively subsidized by society writ large. Society’s willingness and capacity to pay is much better indicated by average income than the income of the median household (never mind issues pertaining to measurement of the income distribution within countries!). Furthermore, the vast majority of health expenditures in most high-income countries are spent on a small fraction of the population in any given year (those that are very sick, badly injured, etc.)


P.S.: It’s my blog.


Median and average are not good representations of a distribution.


Also even media leaves out the poor who can't afford expensive procedures. It's why Obamacare is ultimately doomed to fail too.


Just looking at your first sentence. I assume you meant median, not media since that is what your parent was talking about.

Median actually does a better job of including the poor than does mean. The reason is that median counts the number of affected people, whereas mean counts the amount of spending. Clearly the latter skews more towards the rich, for whom spending may approach infinity.


Average can be the median or the mean. Usually the government reports median when they say average.


I don't think I should be downvoted. This is just a fact. Hell, sometimes it can mean the mode.

https://www.google.com/search?q=average+definition


That's an interesting measure - wouldn't it be biased by the fact that household income in the US is "artificially" inflated compared to other countries, because healthcare costs need to be paid from income?


First, we can assess the degree to which the US is unusual by inspecting the scatter plot. If US household income was somehow unusually inflated by health spending, then it its residual should be much larger than it is (especially in better models that incorporate some of the non-linearity observed in other countries).

Second, just where is this extra income supposed to come from? More likely households bear almost all of the incidence of this spending, meaning each dollar spent on health means approximately one dollar less available to households to use elsewhere. This is certainly what the literature on employer health insurance benefits tends to suggest.

Third, the timing of this is all wrong. It’s clear the arrow of causation goes overwhelmingly from income to health spending because changes in health spending clearly follow changes in income. Over the past few decades it takes an average of about 2-3 years for changes income to be fully reflected in changes in health spending due to the large role played by 3rd party payers, employers, etc (the current year elasticity is about 0.2 whereas the long-term elasticity is north of 1.6).

~RCA


The graph is already adjusted for PPP, so this difference in income should be largely mitigated, shouldn't it? Thus the US still spends about double of other countries.


One challenge is the mix of spending is actually quite different even adjusting for GDP!

Adjusted for GDP, US spending on inpatient procedures is somewhat inline. However, spending for outpatient procedures is way higher. Americans just have a lot more outpatient stuff done than other countries.[1]

[1] McKinsey analysis of US healthcare spending; search my history for actual link or google it!


Honestly, how do people become so easily convinced that price controls would work in healthcare when they don't work anywhere else?

Inventing a fancy index is not a replacement for "price fixing". And price fixing does not work. You reduce supply.


This could also be due to people in the US simply seeking more care than in other countries.


Even if that was true it doesn't necessarily map. Preventative medicine is known to reduce costs considerably for one. Paradoxically healthcare can be expensive because people aren't getting enough care.


FWIW, this isn't what I observe.


What’s the logic in that? If the cost is socialised surely you’d expect more people to seek care than if they were paying?


What’s the logic in that?

Am I going to get a quad bypass just because it is cheaper?

People seek care because they need it. The kind of care that people use more because it is cheaper/available is maintenance care (which reduces overall costs because things are often treated before they become critical).

The first time I heard “I am feeling sick / cut my hand / need stitches but I cannot afford to go to the doctor” was in the US, and it left me dumbfounded - I have lived in a few places, and that’s a US only thing.

Also, I could understand some of George Carlin’s jokes (e.g. “dirty doctor” one) until I had lived in the US.


I think I didn’t make my point clearly. The post I replied to was suggesting that Americans seek care more than others and that’s why costs are higher. I didn’t think that likely, and argue that direct exposure to the cost would lead to people seeking care less often.


That's not true in my experience - it seemed like Americans seek less care, because it was expensive; but when they do, they seem to want to medicate everything away and go back to work ASAP (even if it's something that heals on its own, and even if it means taking painkillers for a while and risking complications), whereas in other places, it is acceptable to let many things run their course, and mild discomfort is considered acceptable.

E.g., in the netherlands (and IIRC also in Germany), it is considered rude to come to work when you are sick - you expose everyone else to risk, for a work day that's likely less-than-effective (because, you are sick) -- whereas in the US, you're expected to just pop an advil and show up (and .. if you are visibly suffering, you'd be considered a hero).


Utilization increases with decrease in cost.

In argentina I remember calling a doctor home to check up on a cold. This would be unreasonably expensive in the US for very little healthservice in exchange.


I think there's a balance to be found. Here in France people will go to the doctor for a common cold, and immediately load up on unnecessary medicine at the pharmacy. I'm sure that if they were asked to pay even 5E out of their pocket it would significantly reduce the shortage of GPs and the lower costs.


Israel tried this a decade or so ago - something like 10EUR/Qtr if you've used any services, and additionally 1EUR/visit -- both of which would be waived if you were in really bad financial shape.

IIRC, it made zero measurable difference on the number of visits, but the bureaucracy involved with charging this was costing more than than the money collected, so it was eventually scrapped.

(I might be mistaken, an Israeli versed in how the system works / worked is welcome to correct me)


“I have cancer and I went to the doctor and they gave me painkillers” is a non-US/EU thing.


I think it’s cultural; strong families/communities seem correlated with not wanting to be a burden on that family/community when your time comes. Individualism, as in the US, seems more correlated with trying to stay alive/healthy at any cost.


Please. You cannot be serious. Are you really saying that pricing in the US healthcare system is so broken that the only way to set prices is to take other countries prices and convert them?


It would certainly be a good start.

In fact, the US could improve a lot of basic services if it looked at what other developed countries (OECD) are delivering, and for how much, and made those targets for the next lets say ~10 years.

After those 10 years of bringing the US more into line with the best countries in the world, it should strive to do even better.

Or, alternatively, the US can keep falling further behind.


This applies to quite a lot. Banking, legal, infrastructure, political systems etc.

It amazes me how the US is still arguing how archaic districting laws should work, how to have elections with integrity or manage without paper checks or fax machines.

I realize there are politicsl/historical and cultural differences but there is a combination of exceptionalism (“the US is so special we can’t just look at France and imitate”) and resignation (“yeah we want that but we cant have that because it would never work because X”) surrounding each of these discussions. The US is pushing boundaries in so many areas but when it comes to evolving society in a way that requires broad agreements, there isn’t much to report on


“The US” is not a entity unless you’re saying we should convert to a single payor system, then set prices based on rest of world pricing.

I can tell from first hand experience. Healthcare companies, set prices by market. Specifically, by what price that market will sustain. It just so happens that the US can sustain the highest prices. You know being unregulated and rich af and all.

This is how all industries/companies set prices btw. What you’re saying, It’s kind of like saying, I want New York City to base real estate prices off median home prices in the Midwest because as a buyer I like those prices better.


From the point of view of people from other countries: Yes. Your pricing is fucked up.


That sounds like an awesome idea if you completely ignore all the important things about healthcare differences across countries.

In fact, it sounds like a great way to make things worse!


[flagged]


You sources have nothing to do with my reply.

“Tweaking” the system is how the US system got so messed up in the first place. Anyone who suggests “just one simple tweak should fix things” is an idiot.


This is one of those nice ideas that has some pretty serious hidden costs. You’d struggle to compare healthcare in the US to other countries, because the quality of healthcare available (talking about availability, not accessibility) in the US is generally superior to other countries. So you could end up simply eroding the quality of care in the US. Another thing people tend not to talk about when discussing healthcare in the US is how much the US contributes to medical research and innovation. No other nation on earth even comes close. If you adjust the system so much that you remove the incentive to carry out that research, then the quality of care in literally the entire world would suffer.


I disagree about quality/availability. In Japan, Taiwan, Mainland China, Thailand; I’ve had amazing health care for the fraction of the price. Shit, a full cancer check only cost me 90 dollars in Japan. Getting my eyes fully checked for retinal tears cost me nothing due to national insurance in China.

In some cases, maybe the US has better care. But the cost of that is just way too damn high.

Yes, medical research in the US is superior, but that shouldn’t be at the cost of peoples’ lives.


The US health care is optimised for the the p99, top 1% of the population who can afford anything. The other countries you mentioned optimise for the p50, the average person.


p50 would be the median, surely?


Technically, mean, median and mode are all averages. Handily, parent clarified what they meant.


In the developed world, the price of routine checkups are not what people would generally be referring to when discussing _quality_ of healthcare. Generally speaking, the US has the best facilities, technology, expertise and pharmaceuticals available. Which is why people come from all over the world for procedures that simply aren’t available elsewhere. Again, I’m not talking about the problems with accessibility, merely talking about available treatments.

Reducing investment in medical research will absolutely come at the cost of people’s lives. More people’s infact, as anybody will die from a terminal illness that doesn’t have a treatment. As an example the US market constitutes something life 70% of _global_ pharmaceutical profits.


This weird argument pops up regularly. In relation to New Zealand (where I am) it’s argued that the US is subsidising the cost of drug scripts. It’s beyond me quite how NZs drug buying agency is running roughshod over the rights of drug companies that have multiple insurance companies in the US that are bigger customers. What’s the agenda behind this argument?


The U. S. is the last place drug companies can get away with it, is what the agenda is. Americans are suckers for a good capitalist argument. “U. S. customers pay more because they have to subsidize those filthy socialists.” Imma gonna have to call bullshit. You’re telling me you sell to NZ at a loss because...New Zealand tanks will roll up to your doorstep if you don’t? Does New Zealand even own a tank? No, you sell to NZ because you somehow figured out how to profit from doing so.

But as we see above, plenty are willing to carry the water of the poor, downtrodden drug companies.


>No, you sell to NZ because you somehow figured out how to profit from doing so.

The incremental cost of selling drugs you’ve already developed is quite low, so of course they can still profit from them in less profitable markets. But it’s the US that’s paying for them to be developed. This isn’t even up for debate, R&D in the US dwarfs everywhere else.


There’s no agenda behind it at all. If profits in the US market go down, they either have to go up elsewhere, or investment has to go down to match. This is very basic maths.


This argument does not at all reflect the actual revenue model of pharmaceutical companies here in the US.

In the private sector, far larger amounts of funding are spent on marketing than research[1]. The basic maths shows: investment in research can be maintained or even increased while providing greater access to the fruits of that research.

The money is there. What we lack is the proper incentivisation.

1. https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-p...


The flaw in this is that for-profit medical research optimises ... for profit, that is, the treatments for which most can be charged.

So they focus on illnesses of the rich gerontocracy while diseases of the developing world have to be addressed by public funding. Additionally, there's no real incentive to work on cost reduction.


In my experience, Russia had a decent healthcare system in the Soviet era. Care was (obviously, I guess) pretty much free. Most physicians were female. And most of them were apparently driven by moral conviction.

The US was rather a shock for me. Costs were mind-boggling, and most physicians struck me as jerks. At least, the male ones did, and they predominated. Nurses, on the other hand, generally seemed OK.

Somehow the US healthcare system seems to attract jerks for physicians, and they seem to be mostly in it for the money. Not all of them, obviously. But enough to set the standard.

I have no clue how that happened. Or how to reverse it.

Edit: Some might ask why being "in it for the money" is bad. I mean, that's what "free enterprise" is about, isn't it? But think about it. Is it OK for priests/minster/rabbis to be "in it for the money"? Or politicians? I hope not. And then, why physicians?


This is anecdotal. To counter, my family have had very good overall experience with physicians in the US. Moreover, my college friends who went on to become physicians are all people I'd happily take my own family to see.

One of the problems with care in the US are clinics that treat Drs (and NPs and PAs) essentially as billing machines, and don't allow them any time to build any rapport or relationship with patients. Depending on your insurance coverage, your location, and your needs, your experience will vary wildly.


Yes, it's just my experience.

For what it's worth, my experience teaching premeds was also not so great :) That's also anecdotal. But colleagues had similar complaints.

Also:

> And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. ... A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.

> The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies.

> Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians.

https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...

Also see https://www.politico.com/agenda/story/2017/10/25/doctors-sal...


Medical research in the US comes out to something like $500/year per capita. It’s doesn't come anywhere close to accounting for the cost differences between the US and other first-world countries.


I didn’t say research alone did. I said that when you compare investment in research, as well as the quality of care, you’d expect the cost of healthcare in the US to be higher. As much higher as they are? I don’t think so. But if you want to fix the accessibility issues without impacting innovation and quality of care, then you’re going to need a solution slightly more thought out than hamfisted price fixing.


> as well as the quality of care, you’d expect the cost of healthcare in the US to be higher

If the quality of care is so amazing I'd expect Americans to have longer life expectancy, and they don't.


As a parent poster noted, the system is optimized to provide amazing care for the people who can afford it ... and those people do have longer life expectancy.

https://www.vox.com/science-and-health/2018/1/9/16860994/lif...


You're implying that both the quality of care and the amount of medical research done is a result of the profits of the medical companies. I'm not sure that this is the case.


Profit is the only thing that drives investment in care and research. You’re asserting that you can reduce profits via price fixing and still deliver the same outcomes in both care and research.


Profit is the only thing that drives investment in care and research

This is manifestly untrue in so many domains, including medicine. Most research is heavily government funded, particularly pure research, and most academics are not interested in profit. The only orgs motivated by profit (drug companies, insurance companies) are the ones who push this misconception, because they profit from it. As one example, the UK runs large trials comstantly to improve care, without a profit motive.

Nobody has to postulate that price fixing (as you call it), or single payer healthcare without insurers works better, because the rest of the developed world outside the US uses that system and delivers very similar outcomes for radically lower cost. The facts are clear.


Whose profit?

If you refer to the professionals’ compensations that’s correct, but not that useful as it applies to all of the adult working population.

If you’re referring to the capital accumulation of investments in healthcare companies, you’re off the mark, as there are several examples that falsify your statement, even in the US


I disagree from personal experience. Location of where you are in the US matters. I'm in Montreal right now and the mental healthcare here is superior than what I experienced in the US in Michigan (majority of my life). I would even go as far to write the mental healthcare in USA, which I received ruined my life. If only I had the pleasure of what is available in Canada for my whole life.


The further toward the poles you go, the more mental healthcare is needed, so it makes sense they would have the experience and infrastructure! (Completely serious.)


This isn't necessarily the case with my situation. There was only one hospital for where I lived in Marquette, Michigan. My mental healthcare was pertaining to gender dysphoria and not depression which I think you're associating with longer winters. Anyway place I grew up was filled with religious nuts to make things short. They forcibly prescribed me with antipsychotics while ignoring my right & modern medical approach of gender dysphoria. Montreal is a large city compared to that place and is progressive like California. So basically where you're located when it comes to social structure is huge.


I think small rural town versus major metro center has more to do with the quality than US vs Canada.

It’s no different in Canada - small towns don’t offer as good of care particularly when it’s something that’s not common.


I think I might have heard this at some point in the past.

Anyway, I found a reference to support your claim:

Also consistent with the conclusions of Torrey1 and Saha et al,2 our analyses shown in table 3 found a strong tendency for prevalence to increase with latitude.[1]

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669590/


I'm not aware from the article of how the illness "schizophrenia" foreshadows all of mental health. My illness being Gender Dysphoria.

Vitamin D deficiency from what I've read is common everywhere. It does make sense that longer winters would impact a person such as staying inside more. Yet I doubt any evidence can confirm lack of Vitamin D is associated with the illness schizophrenia.


Ah, yeah, that's a good point. Schizophrenia is probably a poor proxy for all mental illness.

And there's probably at least quite a few things that aren't mental illness that benefit from mental healthcare.


The Indians have better cardiac surgery outcomes. I don't care about anything but outcomes. It's no surprise, though. Their guy has done 150 surgeries in the last year. This guy has done maybe 40. No good. If things are so much better here, why are outcomes not as good? IMR, MMR, even with companies that have comparable or stronger definitions.

The evidence is constantly against US healthcare except for experimental or rare treatments. The doctors aren't any worse, surely.


At the top end, this will be true. Surely, a well-trained surgeon is a well-trained surgeon and mechanically they should all have roughly equivalent skills. The difference lies in experiential knowledge: knowing what to do whilst in a surgery, based on practical experience and seeing similar patients. We've interviewed four of the top pediatric cardiology centers in the past two months, searching for the best treatment option for our daughter, and only 1 of them has a research focus in the needed area, accompanied by a specific treatment protocol and specifically trained staff. That's not because the other hospitals are "worse". It's a result of our daughter's need being extremely rare, with very low demand. Even the above-mentioned hospital only sees ~1 patient per month (compared to maybe 1 per year or fewer at the other hospitals).

I 100% agree: experience is key ... but so is a clinic's/hospital's internal investment in any given speciality. And if it's a teaching/research hospital, so then is publishing by its clinical experts.


The specter of price controls.

They dont work, simply because if you limit payment then hospitals will stop doing the procedure, will fight against doing them, and will engage in high cost cutting to provide them. Please remember that about 60%+ plus of hospitals are non-profits: they only bask in the profits for their own salaries, but don't have the profit-based mentality usually accussed of.

You might want them to do that, but I doubt the market will agree with you on that one.


> My guess is that eventually the govt will step in and start regulating prices if providers don’t.

There will be a heavy pushback from industry about how that’s socialism, delivered via Fox News and other conservative outlets.


Well that is socialism. (As is our conflation of insurance and charity.) Being a form of price control, it also happens to not work very well.

EDIT: and if anyone can explain why forcing doctors and hospitals to provide their services at a loss, is not socialism, then feel free to reply; as that will be assuredly more enlightening than a simple downvote.


I didn't downvote you, but I'll take a stab at this!

> Well that is socialism

As indeed is provision of roads, fire trucks, police, military and so on. For some reason, people rarely call those out

> Being a form of price control, it also happens to not work very well

I think there's a strong strong case that it works very well in every rich country, because they're all doing it to some degree?

> forcing doctors and hospitals to provide their services at a loss

This assume they're not currently making super-normal profit, which I'm far from convinced by.


>As indeed is provision of roads, fire trucks, police, military and so on. For some reason, people rarely call those out

Personally I would call out. But hey, so what if I did? As you rightly pointed out most people are convinced that they need the govt in their _many_ aspects of their lives. I'm outnumbered by people who think, that they can decide what is good for me as an individual.


Why put a minimum? Why not just the cap part?

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