Why Medical Bills Are Killing Us (2013) [pdf]

That's a thoughtful piece, with some interesting suggestions toward the end. Your "tl;dr" is not inaccurate, but I hope people will read the whole thing.

Can you get a private MRI without a doctor's requisition in Australia? I know in Canada they try to burn you at the stake if you do that.

I used to work at M.D. Anderson and I can attest to their quality of care. People travel from around the world to receive treatment, for good reason.

Also, my mother was a patient there. She started treatment just a couple of months after I got my job actually. She's still doing well years later, and is glad she waited an extra month to get into M.D Anderson. The decision to wait was excruciating though.

Someone I know was diagnosed with cancer. In Oklahoma they were prescribed a treatment plan. They went for a second opinion at MD Anderson. Anderson said that plan was dangerous and very well might lead to a bad outcome. The Oklahoma team said MD Anderson's plan would lead to a bad outcome. MD Anderson gets tougher cases and has the best overall outcomes of any hospital in the world so they went with them.

They're fine now and the standard of care at MD Anderson is mind blowing. At MD, a nurse comes in to draw blood and the whole routine is an organized set of steps. If one step changes, they throw away the kit, wash their hands and start over. In Oklahoma nurses just kind of did things however they wanted and gloves seemed more to protect them from the patients than to protect the patients from an accidental infection. There was just zero comparison in the overall standard at MD Anderson. Add in their outcome averages and the question becomes why wouldn't someone travel from Ohio to Texas.

The medical system should choose the most viable care for them. They are not meant to be experts in this stuff, right?

As a person who consumes capitalist medicine in India, I don't see how any of your issues are fundamental to capitalist medicine.

There is plenty of competition among hospitals. You can choose which one to go to (from an ambulance or any other time). Customers are strongly price sensitive and prone to comparison. There are plenty of choices as to where to go.

Assuming I'm well enough to travel, I'll always fly to capitalist India to have my medical work done.

And again as a Capitalist: You take a high value, required product, mix with a group of consumers who don't have a choice whether or not to buy, and a business minded person with no ethical compass whatsoever and you'll have record profits and screwed customers. Simple as that.

So do you believe that Indian doctors/other medical types are just vastly more ethical than the (very often Indian) doctors in the US?

No doubt, prices have gone up even more.

There's hundreds of things that can be done to chip away at them.

A pet peeve of mine is certificate of need laws:

http://www.ncsl.org/research/health/con-certificate-of-need-...

The notion is to reduce capital expenditures and save costs, but they are a big part of why the hospital in the article can get away with charging so much for cat scans -- there's no competition. Of course it is going to be difficult to go to an outside imaging center during an emergency room visit, but when the outside imaging center advertises $500 prices, the patient will at least know there is something a bit fishy about the $3000 bill from the hospital.

They probably make a lot of sense for something like an ER, where there is a high up front cost and a lot of staffing costs and you can make reasonable predictions about demand. They don't make any sense for equipment that only used to be expensive.

A great book on this is Healing America by T.R. Reid, who saw doctors in eight countries about his bum shoulder and wrote about their healthcare systems. Interestingly, single-payer isn't the only good option, or even necessarily the best.

Canada was the only country with single-payer like we talk about in the U.S. The U.K. is single-payer but also single-provider, the doctors work for the government-run healthcare system.

But the best results were in France, Germany, and Japan. They function a lot like Obamacare (multiple insurance companies, though all non-profit, and mandates to buy insurance). However, they add several critical features:

- Government controls on the price of services. Doctors make a lot less money than in the U.S.

- No claim denials allowed for anything on the national price list. If a doctor prescribes it, prompt payment is guaranteed.

- Good digital medical records.

According to Reid, a lot of German doctors don't bother hiring office staff. They swipe your medical card, get all your records, prescribe what they want, and get paid in a week. They can charge less because their costs are lower.

At least one of those countries also has subsidized tuition for medical school, I think Japan. Japan has the lowest costs (only 5% GDP on healthcare, with great outcomes despite an aging population of smokers), and the tightest cost controls; e.g. they make do with simple MRI machines without a lot of bells and whistles, but they do the job, and an MRI costs $100. Japan implements their mandate in an interesting way: you're free to not pay, but if you go to the doctor and you want it covered, you have to pay your back premiums.

Anyway, it's a fascinating book if you're interested in this stuff.

Routine medical care should be like food and shelter: something you are expected to pay for yourself. That would put price pressure on providers. Insurance should be a backstop for catastrophic accident or illness. It should be sold by competing local and national providers. It should be untangled from employment as a benefit. You should buy it like car insurance.

Obama, Trump, Clinton. senators, representatives -- none (or very few) of these people have any medical background and really can do little else but screw it up as badly as if the government was the single provider of all software.

Relevant quote from the article re: what an effective solution needs to achieve:

>The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market. Congress has given Medicare that power when it comes to dealing with hospitals and doctors, and we have seen how that works to drive down the prices Medicare pays, just as we’ve seen what happens when Congress handcuffs Medicare when it comes to evaluating and buying drugs, medical devices and equipment.

> Stripping away what is now the sellers’ overwhelming leverage in dealing with Medicare in those areas and with private payers in all aspects of the market would inject fairness into the market. We don’t have to scrap our system and aren’t likely to. But we can reduce the $750 billion that we overspend on health care in the U.S. in part by acknowledging what other countries have: because the health care market deals in a life-or-death product, it cannot be left to its own devices. Put simply, the bills tell us that this is not about interfering in a free market. It’s about facing the reality that our largest consumer product by far — one-fifth of our economy — does not operate in a free market.

The article's list of actionables seem like a good first step:

> We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them.

> we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000

> We should outlaw the chargemaster.

> Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head.

The idea that Trump is unencumbered by campaign contributions is a pipe dream, because he has to buy the loyalty of Congress in order to pass laws, and they are more encumbered than ever.

It is immoral for someone to profit from denying someone healthcare. As I see it healthcare is a scare good and the Canadian system is the way to go. But socialism and all that... won't happen in the U.S. any time soon.

I'm for single payer but it will never happen until Democrats get the White House and congress. Paul Ryan is planning on privatizing Medicare asap

That's spending though right?

Part of what the article is saying is that spending isn't a great proxy for cost.

The root cause is aging. You can exercise religiously and never touch sugar, and at best that will result in racking up huge medical bills in your eighties rather than your sixties.

>US healthcare expenses increasingly go to treating conditions caused by poor lifestyle choices: obesity, substance abuse, and sedentary lifestyles.

Nice rhetoric, but source?

Current insurance plans don't help much with preventative care. While a yearly 'physical' involving an 8 minute talk with a doctor is covered, insurance only pays 10% of lab work and a basic blood panel would cost me $900. Checking things like vitamin D levels aren't covered at all.

Victim blaming and false. End of life medical treatment (I wouldn't call it "care") is an enormously expensive and often ghoulish practice.

Does that $3 million also include the expertise needed to operate and maintain the machine? You also need to account for the money the hospital needs to save to buy a new one when the one they have becomes outdated. Still might not add up to the actual cost they charge for a scan but it would look a bit more reasonable. My guess is the different negotiated rates for insurance plus the low income policies make everything convoluted and add a decent amount of overhead. I wish they would stop this negotiating crap and charge whatever it costs for them to do a scan. At least then I will know how much it will cost upfront.

On average the Spanish pay $223/month on health care, not $50. Spain has a $GDP/capita of $30k and spends 9% of GDP on health care.

The thing is, most people dont need to spend 50 euro per month so millions of people pay in order to not be left out the system if they need it. I need it when I was a kid, so now I pay gratefully.

What's the country?