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Comment by JamesBarney | Hacker News Reader

It's true that healthcare is terrible in the U.S. if you don't have health insurance, but he overstates his case. Chris compares a 1 in a 1000 nightmare scenario to his very average experience.

A $112,000 error happens in the U.S. but is rare. Typically the type of surgery he mentions costs between $20,000-$50,000. Or 50-100% of a the U.S. gdp per capita. This is smaller than in India where the cost of his surgery was 130% of the Indian gdp per capita.

And the issues with rounding errors has to do with the large amount of health insurance in the U.S. not necessarily free market vs. regulation. When the majority of consumption in a market is driven by enterprise customers, the pricing can become strange and very unfriendly to individuals.

[0]https://pricinghealthcare.com/prices/IowaCityASC/spine-back [1]http://www.backsurgerycost.com/how-much-does-a-discectomy-co...

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As a patient, US healthcare is terrible even if you have health insurance. Patient is at the bottom of totem pole in US healthcare, and just a number for doctors, hospitals and insurance companies and everyone else involved in the system.

Just a couple of anecdotal personal recent experiences with US healthcare.

1. Recently I witnessed the trouble my primary care physician (PCP) had to go through with insurance company to get approval to perform CT scan. I couldn't believe the 30 minutes, my PCP had to spend on the phone with the United Healthcare person. This is the doctor spending time on the phone explaining all the medical reasons for recommending CT scan and not some administrative person in doctor's office.

This is in contrast to a friend's experience whose PCP kept prescribing pain killers and other prescriptions instead of pushing insurance company for further tests for abdominal pain. The friend later was diagnosed with stage 4 cancer when showed up at ER with same symptoms.

2. While researching a local major hospital rated highly for quality of surgery, I came across the reports of quite a few cancer patients complaining about hospital quickly discharging patients after major surgery and restricting pain medication while in hospital. The claims don't make sense as hospital is rated so highly for Quality of Surgery and might be considered anecdotal. Until I found that two of the measuring criteria for Quality of Surgery was how long a patient stayed in hospital after surgery and dosage and duration of pain medication administered after the surgery. Talk about incentive misalignment. There is all the incentive for surgeon and hospital administration to discharge you quickly to maintain and improve Quality of Surgery rating.

Have you considered that discharging patients to their home, and moderating their pain medication, may actually be signs of quality care? "The patient gets what they want" is not the only sign of quality.

That is certainly true. Nevertheless, I believe the parent's point stands. "Gamifying" metrics such as time-to-discharge and pain medication usage will certainly alter the incentives of such an institution.

I would like to hear more about how discharging patient early and moderating pain medication is a sign of quality care?

The author of original article mentioned staying in Indian hospital for 4 nights. Do you think a US hospital will keep you 4 nights for same surgery? I seriously doubt it. You most probably will be released few hours after the surgery or at most after overnight stay. Is the quality of care becomes lower because an Indian hospital kept a patient for 4 days instead of 1 day by US hospital? What does it say about relationship between quality of surgery and all these metrics such as duration of hospital stay, pain medication dosage and duration?

I found a lot of studies which used hospital stay duration and pain medication dosage and duration while in hospital as a proxy to quality of surgery but none that showed these metrics have anything to do with quality of surgery. Also, while quality of surgery takes into consideration the pain medication dosage and duration in the hospital, it ignores the pain medication dosage and duration patient was prescribed after being released from hospital. Similarly the overall healing and recovery time required by patient after the surgery is ignored in favor of the portion of recovery time patient spent in hospital. Hopefully, you see the incentive misalignment and mis-measurements.

You will get what you measure, nothing more nothing less. It is up to you to decide whether a measurement is relevant or not to what you trying to measure. You should not only worry about what a statistical study show but also what the study doesn't show.

You can argue all you want about whether it's a good metric for surgery quality or not, but if you're being discharged soon after surgery, the idea is that your surgery went well enough that you don't need to be around $50mil worth of life-saving equipment 24/7. It has a valid place in the system, with pros and cons like any other metric.

Hospitals are full of all kinds of hard-to-kill microorganisms. They really are not good places to stay after a major traumatic event (e.g. surgery) if you don't need the resources of the system; staying will only increase your chances of getting a life-threatening infection. When I get home from the hospital, I try to change out of my clothes as soon as possible for this very reason.

As for pain medication, well...one only needs to look at the enormous rise of opioid addiction and prescription medicine abuse in the USA to see that moderation of these very dangerous medications is in the patient's best interest.

The medical system is far from perfect, but don't operate on the assumption that the people working in the field are ignorant of the problems you're pointing out. There are many things we could be doing better, especially on the transparency and patient education side of things, but it's a huge industry and big ships turn slowly.

Patient education is the only issue here, but most of the public has no desire to know anything about their care. They want a magic pill they can pop which will make it all better and they want to sit in a hospital as long as they feel like. This is because they aren't cognizant of the cost associated with them sitting around like a fool soaking up thousands of dollars in resources per day when they could be sitting at home healing instead.

One of the biggest flaws with the American health care system and single payer as well is that it's removed the cost component from peoples considerations of what care they should receive. We all pay for this idiocy in the form of our skyrocketing insurance premiums. Do you really think people would want to sit in a hospital if they actually had to pay the nursing staff $1000 per day out of pocket? If they had to pay the janitor $20 for coming into the room to clean up the mess they'd made? $200 for the physician followup? Of course not.

The above poster complaining about withholding opiates and statistically backed discharge time frames is a huge part of what's wrong with health care across the developed world- not just the US.

In a sea of difficult-to-deal-with insurance providers, United Healthcare stands out as a particularly awful provider.

If I could snap my fingers and magically disappear any single insurance provider, it'd be United.

For my wife's specialty (ophthalmology), they're they only insurer in our region that requires a referral from a primary care provider for a visit. So, if you have blue-cross and have trouble with your vision, you can just go see an ophthalmologist.

If you have United, you need to call your primary care provider, explain your problem over the phone or (in some cases) go in for a visit, and get them to refer you to an ophthalmologist.

It's a hassle for us, but much much more of a hassle for primary care providers who are wasting tons of time on referrals and paperwork an in effort to save United money. It's a good part of the reason that primary care providers have to have the most support-staff per physician[1], despite having relatively lower reimbursement rates.

[1] http://www.mgma.com/Libraries/Assets/Key-Findings-CostSurvey...

The US health care system sucks. I'm generally happy to be back in the US, but not about this particular aspect of it.

It's more bureaucratic than Italy, costs more, isn't appreciably better, and wastes people's time more.

What's more, even though Italy has a single payer system, there is also private care available that is quick, cheap and efficient - which it has to be, since the competition is "free" (tax funded).

The US has neither a free market, nor a good government provisioned system, but some mess that's neither fish nor fowl.

I'm a dual US/EU (Italy) citizen. This 1000 times. The fact that the US system is more Byzantine than the Italian system is mind-blowing.

An error that large may be rare, but the overall experience of massive/unexpected financial load is fairly common via my experience hearing from customers (full disclosure: I founded a medical tourism startup called Emissary two years ago: https://www.emissarymed.com)

We talk to people all the time who don't have insurance (20-30M last time I checked), don't have dental insurance (~150M), or whose insurance comes with coverage caps as low as $1K-$2K that render insurance effectively useless for them in large operations. Most of the time, customers we talk to actually don't even get as far as the author did, because they can't afford the estimate, let alone the risk of over-shooting it. They just avoid getting treatment (and often get worse in the meantime).

The trick then is how to find a doctor you can both afford AND trust. If you'll excuse the plug, we started Emissary to solve that when a friend's mother had this problem. Our mission is to help connect people to high-quality options they can afford, regardless of where they live in the world.

Love it.

> the large amount of health insurance in the U.S. not necessarily free market vs. regulation

Erm, health insurance companies are essentially the opposite of a free market. They're as close you can get to government run without actually being called "government". With USG's recent push to make patronizing these behemoths mandatory, even the last little sliver of "exit" has been lost.

Take a look at http://reddit.com/r/personalfinance for a few weeks and you will see that there really is a problem.

It's very true that I don't know what average costs are, in either country.

The only prices I know are the price at the place I went (one of the top facilities in the region) and a few nearby hospitals. Several were significantly cheaper and if I earned in INR I'd probably have gone to one of them. But I figured that given how much I enjoy walking, why not just spend $700 more to go to the best guy?

Not three years ago, with "comprehensive" insurance, I paid $7000 for a kidney stone, with a full total approaching $50-60K.

For a kidney stone. I had to have two surgical procedures, admittedly - they went in to remove the stone, found long-standing infection, closed up and catheterized. A week of antibiotics later I had it shocked.

But still... $60K for a kidney stone.

That can no longer happen (since January 1, 2014). Insurance policies now have out-of-pocket maximums thanks to Obamacare. The 2016 limits are: $6,850 for self-only coverage and $13,700 for a family plan.

So you would have stopped hemorrhaging money at $6,850, and then the insurance company would have been 100% responsible for the rest.

Still, $60,000? That's more than an average US salary for an entire year.

What?

I realize that. I work in the health "insurance" industry (as a vendor).

Notwithstanding that, it was considered a voluntary procedure, though there was no way the stone would pass (11mm x 6mm) - average ureter size is 3-5mm and I had to sit in the billing office and work out a 'financial solution' with them prior to authorizing surgery (negotiating anything while in this much pain would probably be considered close to coercion).

As an aside, I really dislike "Obamacare", as a name. The Affordable Care Act. As an aside, a survey a few years ago asked self-identified Republicans this: "Would you prefer some form of affordable care act as an alternative to Obamacare?", to which many replied in the affirmative. There's too much potential for bias.

On the flipside, Obama has endorsed the usage of "Obamacare," because he does in fact care:

http://www.cbsnews.com/news/on-bus-tour-obama-embraces-obama...

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