Show HN: Compare prices that US hospitals charge patients, insurance companies | Hacker News Reader

Show HN: Compare prices that US hospitals charge patients, insurance companies

turquoise.health

447 pointsageitgey374 comments

I think something else that would be of interest would be doing this for drug prescriptions: compare the cost that my employer, the NHS, pay for a compound and those that Americans pay for the exact same compound. This is easy on my end at least -- prices and prescription guidance are released in the BNF / British National Formulary annually and are all made available in public. I have never understood the US system of "co-pays" and found the whole thing very confusing.

For a few "popular" random examples that I think HN might have heard of: one branded Epi-Pen is £26.45; Naproxen (the NSAID painkiller) is £4.29 / 56 pack; and omeprazole (PPI used to treat gastric reflux) is £0.84 / 28 pack.

A more expensive example might be the cystic fibrosis "designer drugs" lumacaftor with ivacaftor -- 112 tablets are £8000 (to be prescribed by a specialist, if the patient has the genotype to respond to it -- a total annual cost of about £26k). The US equivalent is $379,780 [1].

(NB: The price you pay as a British patient is usually £0, unless you are a working-aged and working English person -- at which point it is £9.15 per item [independent of its cost] or a fixed "all you can eat" prepayment certificate that works out at about £8.83/month -- which is what I have. Oh, and plus the taxes, of course...).

[1] https://www.jmcp.org/doi/pdf/10.18553/jmcp.2018.24.10.987

> I have never understood the US system of "co-pays" and found the whole thing very confusing.

I think you're mixing up a few things here. The co-pays are meant to make the patient directly pay some of the cost to decrease abuse of the system. There are many different structures for co-pays so saying anything general is kind of difficult, but there are reasonable arguments supporting such a system. In Sweden for example you do have to pay certain costs (which are capped) for essentially the same reason.

But that has nothing to do with the fact that prices vary so widely for the same products and services. Personally I think that the US system should at a minimum require that

1. All medical products' and services' costs to published publically;

2. All costs to be non-discriminatory (meaning everyone regardless of any insurance plan or none must pay the same);

3. All costs be available prior to any services provided.

In other words, there are no negotiated plans with different prices, there are no surprise bills, patients actually are able to understand costs, and real competition is actually theoretically possible. None of this would necessarily preclude an insurance plan from having co-pays, it would just make the only point of the insurance plan purely financial and open as it should be.

Of course the US could just move to a single-payer government-run system, but that's a different discussion. If the goal truly is to have a market-based system, then I think my points above should be implemented.

Not allowing an insurance company to negotiate for the price of a drug or service is precisely why medicare and medicaid have ballooned up to 39% of US federal spending while not even approaching "universal" coverage.

I'm possibly misunderstanding you, but you seem to be implying there would be no negotiation in the system I described. I never said that. You as a patient would in fact be much more empowered to negotiate with those who provide you services, since you would actually know the actual costs available in the market.

However, if your point is that the current system would also be improved by the tiny change of allowing medicare to negotiate prices without any of my other ideal changes, then yes I agree that would be a change for the better.

One of the things that EU countries do is negotiate with the the drug manufacturers. So UK in this case of Lumacaftor, didn't cover the drug until they got a reasonable price. This meant a 4 year delay in access to the drug vs the US.

> It was approved for medical use in the United States in 2015, and in Canada in 2016.[3][5] In the United States it costs more than $US 22,000 a month as of 2018.[6][7] While its use was not recommended in the United Kingdom as of 2018,[4] pricing was agreed upon in 2019 and it is expected to be covered by November of that year.[8]

https://en.wikipedia.org/wiki/Lumacaftor/ivacaftor

I don't think you can really say that the US has "access" to a drug when it costs $22,000/month, which, given the median household income of $68,700/yr, is nearly 4x more than the average American makes in a month.

Many Americans who use expensive specialty drugs have prescription drug coverage and don’t pay the entire price of the drug. And/or they get a discount through manufacturers programs. That said, my insurance does not cover the above drug.

So practically speaking, many Americans have to wait even longer than those in the UK? Even if they have insurance? And perhaps even a well paying job with good benefits (an assumption of mine based on the setting).

I don't know about that particular drug, but I was on a super spendy drug- the manufacturer had a program that would cover the difference down to $5 / month or $25 if your insurance didn't cover it or you don't have any.

My insurance wouldn't cover it until I tried cheaper alternatives first, but I didn't want to try those given their fair more serious side effect / risk profile. Because of the manufacturer program, I was still able to get it for $25. I dont know if that would be possible in the UK if the programs arent offered there.

Also, no waiting period other than the medicine had to be shipped from a specialty pharmacy that could deal with the temperature storage and handling requirements. There is a bit of a wait to see a specialist to actually prescribe it, but that varies by geographic region and specialty.

I don’t follow. What would they be waiting for?

Money to pay the bill.

To some degree, the EU (and Canada's similar practice) forces US consumers to underwrite the cost of R & D that creates many of these drugs in the first place.

Instead of that, perhaps the US consumers are simply being overcharged?

£9.15 per item [independent of its cost]

That's basically what a copay is.

Aren't a lot of copay's percentage based?

That form is more precisely called coinsurance, with the precise definition of copay being the case where you pay a fixed amount of money per occurrence.

The Health Care Cost Institute has something like what you want - see Figure 2 about halfway down this page:

https://healthcostinstitute.org/hcci-research/international-...

> NB: The price you pay as a British patient is usually £0, unless you are a working-aged and working English person -- at which point it is £9.15 per item [independent of its cost]

For comparison of terminology, this is what we would call a co-pay in the US.

You pay 9.15, your health coverage pays the rest. Thus you are “co”paying.

This is made possible thanks to the current administration’s CMS price transparency rule which went into effect Jan 1,2021 http://www.cms.gov/hospital-price-transparency

Edit: By “current” I mean the Trump administration.

And by "current" administration you mean the Trump administration because people here don't like to give credit where credit is due.

I mean, we can discuss how much credit and where it's due, but I'm pretty sure "current administration", on a given date, makes it kinda apparent?

I think the idea is that the poster wants people aware that at least once in his administration Trump has done something remotely correct.

Of course the fact that he did this after spending 3 years trying his damndest to gut our already mediocre public healthcare system makes it a bit of a eye roller, but you know, even a broken clock is right and all that.

For completeness, a couple of other health related actions by the current administration:

- 'Most Favored Nation' drug pricing. Also as of 1/1, big pharma has to charge US payers the same price as the lowest price they charge to other countries. One example cited is insulin. Apparently, the price of Insulin from the same pharma is 10% the price in Canada as it is in the US. Now that this law is enacted, that pharma has to charge the same in the US as they charge in Canada.

- 'Right to Try'. Greatly reduces restrictions on terminally ill patients' access to experimental treatments.

- Removed the mandate on the affordable care act. People who do not have any health insurance were liable to pay a fine. That fine was removed.

- eHealth across state lines. Doctors were not permitted to see patients via video calls across state lines. During the pandemic, that restriction was removed.

We should not ignore the attempt to relax restrictions on Association Health Plans in 2019, which would have made it easier for small businesses to band together to negotiate insurance terms using combined group numbers on par with that of larger corporations. This was struck down by a federal court[0], but would have moderately improved one of the biggest barriers to small business ownership/employment - unobtanium health insurance. This was a huge loss of something almost great.

[0]https://www.shrm.org/resourcesandtools/hr-topics/benefits/pa...

The better, and simpler option is to remove employers from the equation entirely. Either go with taxpayer funded healthcare, or force everyone to buy from healthcare.gov where they can choose whichever insurance company they want.

In terms of moderate tweaks to an enormous problem, AHP reform for small businesses is comparatively low-hanging fruit that could help businesses today meet the minimum requirements for attracting talent - health insurance. Your proposal may be better in the long term, but the journey there is not simple by any means.

My proposal could be done immediately. All the infrastructure already exists. Remove the tax deduction for employers, give it to individuals on healthcare.gov, job done. Or ban employer sponsored health insurance and don’t offer anyone a tax deduction.

Either way, it’s all just a matter of changing regulation. The real problem is big business will lobby against it because it gives them an advantage over small business, and a leash on employees.

> immediately

Theoretically only, perhaps. I feel like you're overestimating the ability of our regulatory bureaucracy to implement change, or assuming that if you (or I) were dictator the proposal could be done immediately. But imagine flushing out that proposal nationally, getting it through the Legislature (with all the conflicting interests of the medical field, employers, etc), President and then implementation. Comp structures nationally would radically change, so such an overhaul would have to be phased in even if you did get through the gauntlet of bill approval.

Getting it through legislation is the only problem is what I mean. People can already purchase insurance on healthcare.gov. The infrastructure, the sellers, the pricing is all ready to go with no work. The insurance companies already do the same work so it’s not even like they need to hire people. It’s just cutting out a middleman.

Only politics is in the way, and current entrenched interests not wanting to lose their advantages.

'Most Favored Nation' drug pricing is currently blocked in court. We don't know how this will play, if it works.

Given that all the current HHS political appointees have handed in their resignation letters for use in less than two days, "current administration" will become inaccurate during the lifecycle of these comments - maybe that's the reason for clarification

Everyone knows who the current administration is, assigning a name of a bobble head to it doesn't mean anything.

The bill [1] was introduced by Mike Braun and others. None of which have anything to do with Trump or his "administration", these are voted governs who did this all on their own.

1 - https://www.congress.gov/bill/116th-congress/senate-bill/410...

Out of curiosity, how much will this reduce the cost of health care? The idea, as it's been explained to me, is that visibility into the cost of medical care will result in downward price pressure. How much?

Transparent pricing enabling the comparison of pricing between different sellers is only one piece of a functioning marketplace. You also need multiple informed sellers and multiple informed buyers.

So it's a step towards a complete policy. What is the complete policy? Granted we might not see it enacted now, but it would at least clarify where the administration was headed.

Increasing supply of doctors by increasing residency funding, decreasing education costs, and decreasing the sacrifice that needs to be made to become a registered doctor.

I have no idea why doctors need to sacrifice their entire 22 to 30 year old lives constantly slaving away, working on call, sometimes 24 hours at a time.

Relax some of the draconian, outdated hazing rules. Attract more smart people, make it so young people can have lives and become doctors.

That might address the cost of labor. The cost of medicine on the other hand is simple, the government should be funding research into medicines and then offering it for sale at basically the cost of production. Only other way is to reform patents and whatnot, but it seems easier to just do the research with the top tier research facilities the US already has via the higher education system.

There’s probably some other issues such as tort reform and medical equipment costs that need to be address too. But I think all prices can be brought down by increasing supply.

Indeed, bringing down the cost of med school might also have the effect of attracting people with a working class background, who see it as a form of labor, not as a return on an investment.

I'm not sure what the impact of tort reform would be. It's possible to look up how much is paid in premiums, but we don't know who owns the malpractice insurance industry, and I've read that it's doctors.

There’s two costs to the US legal environment: Insurance premiums and defensive medicine. It’s in the doctor’s interest to run every test because it’s free to him, but failure to do so raises his risks. So you wind up spending money non-productively and you have a non-zero rate of false positives, unnecessary treatment, etc.

Interestingly, I think they may be bringing that cost under control. I had an injury recently, and it took 2 trips to the doctor (each one with a fee) before they agreed to do a cat scan (with another fee) and find out what was actually wrong with me.

100% with you on the idea of increasing the supply of doctors and shortening medical education.

My dad is an ophthalmologist and he does basically 3 surgeries that take up most of his work time: LASIK, cataract surgery, and cornea transplants.

Was it really necessary for him to do 13 years of schooling to learn how to do those 3 surgeries? I really don’t think so. I feel like we could train doctors in about 6 years (2 years of focused medical training + 4 years of residency / apprenticeship with a practicing doctor). If we’re honest about what doctors are learning, they would have about the same amount of time learning about their actual specialty compared to now, without so many hoops to jump through.

The current system is a cartel that must be reformed.

We also should consider international competition. There are competent doctors in India who could do expensive surgeries like hip replacements for 1/10 the cost AND get better results than the average hospital in the US.

At least we could sell health insurance across state lines...

The AMA effectively controls the number of Doctors. They do this by limiting the number of accredited Medical schools and the number of students those Schools can accept. This is primarily to artificially drive up salaries.

The current tax code incentivizes insurance as compensation, which drastically distorts the market. The ACA made things even worse by introducing the individual mandate.

Indeed when ACA was passed, it was acknowledged that it was intended to reform access to health care, not the cost of health care. It was a compromise that appeased the insurance industry.

The ACA made things better than they were by eliminating maximum benefit amounts, implementing out of pocket maximums, implement maximum age rating factors, and removing all pre existing condition clauses guaranteeing access to healthcare. The individual mandate ensured that all of these increases in access to healthcare could be paid for by forcing young and healthy people to pay premiums. Without the individual mandate, premiums would have had to be even higher, causing even more people to not buy insurance, etc.

That the tax code was not updated to remove the tax benefit for employers, or give it to individuals is a shortcoming (and has long been a handout to big businesses prior to ACA). What really needed to happen was forcing everyone into healthcare.gov onto a single marketplace so healthy lives wouldn’t be locked up in employer sponsored risk pools. Then the costs would truly be shared across the whole population, and sufficient healthy lives would exist to enable multiple insurance companies to compete.

Or we could have gone with taxpayer funded healthcare and made it all simpler. But that obviously wasn’t in the cards.

For example, an appendectomy (MSDRG 343) in my area will cost $56,000. With my insurance plan, that will max out my $8,000 deductible, + another $8,000 co-insurance to hit my out of pocket maximum of $16,000. That's what I'd pay, $16,000.

Or, I can go to Tennessee and get the appendectomy (MSDRG 343) for $4,700 and pay that directly.

Many people will make that choice Kaiser gets less business putting downward pressure on their pricing. And the folks in Tennessee might see they can raise their prices so that it starts to equalize to some point.

How many appendectomies are elective? I was immobilized by pain and possibly close to death when I had mine. The economic impact depends on actually realizing the cost savings, which could be compounded by a variety of factors.

True, appendectomy was not a good choice. Perhaps hip replacement would have been better.

It's complicated so nobody really knows. I've seen a few studies that have showed real but modest effects (2-5% decrease). The benefits tend to be concentrated because most healthcare spending is on patients who don't have an incentive to be price sensitive.

Personal opinion (as a health economist) is that this is a nice policy, but probably not going to do that much.

You as a consumer now have the ability to search, but do you have an incentive to do so? Do the savings come to you?

Some of it, perhaps. But it's likely not that much and only under some circumstances.

E.g., if you are just faced w/ a copay on a visit, your copay is going to be the same at two facilities.

Coinsurance is different - there you may realize some savings. IF you are below your deductible for the year that is also different. You may realize savings and care.

But there are a decent number of patients who for most of their visits will not see much incentive to search.

Also... it is possible for these releases to help hospitals coordinate on prices in a way which they currently do not. (Tacit collusion, not explicit, back-room, definitely-illegal collusion.)

Hospital A now knows exactly what Hospital B gets from Aetna, so Hospital A may realize it can hold out for more w/ Aetna b/c Aetna is willing to pay their competitor more for the same procedure.

Both of these questions are above all empirical questions and one to which we do not yet know the answer. I would be wary of confident predictions.

As an economist thinking about a move into health economics, could I reach out to you to discuss opportunities in the field?

I respectfully disagree to one piece of your logic.

The effect. The effect will be strong.

The logic that you posit to contradict this is that for most patients "there will be no incentive to search for better prices". That seems to ignore entirely the dynamics of other established businesses like supermarkets.

Most people go to supermarkets and the vast majority are not looking for the absolute best price or even the median price. However supermarkets battle out in pricing to catch the few customers that they know are price sensitive. Its the minority rule. This is a positive externality by which everyone benefits.

This same dynamic will be observed in healthcare.

I agree in that much of it is unknown and also the time horizon is very uncertain. But the effect will be felt and it will be profound.

This is meant to put market pressure on medical svcs. This new transparency rule only applies to hospitals, it does not cover independent Practices.

There will be several 2nd order effects, where the overall impact is unknown: 1. The transparency rule not only reveals prices to consumers, but also to other insurance companies and other hospitals. Since these price arrangements were until now secret, that will impact negotiations between payors and hospitals in competitive markets like major cities. This is likely to force outliers on both the cheap end and expensive end to bring their rates closer to market. If either hospital or the insurer cannot bring their rates closer to market, this may accelerate consolidation of hospitals to improve negotiating power, and/or cause smaller insurers to drop hospitals from their network. This may give some room to relief to small practices that were formerly in danger of losing payor "network" access; at least while the big coverage fights happen upstream between hospitals and payors.

2. the transparency list is not comprehensive. So, not all medical services are shoppable (i.e. scheduled in advance, typically non life-threatening), this may cause hospitals to shift costs to services that consumers have no control over, meaning (1) emergency and (2) unlisted procedures. It will take a few years for hospitals to understand the impact the rule has on their bottom line. The implication is that there will be a waterfall of margin pressure on scheduled procedures at independent doctors , but it will take time to happen.

Walked into a clinic for a weekly shot. Paid 60 dollar co-pay each week.

One day I asked how much go get shot without insurance.

It was $15.

I was paying 4x to use insurance. And insurance was getting billed on top of that.

Did you switch to getting it without insurance?

Same happened to me. A test with insurance cost $3000 with insurance. They paid $2250 leaving me with $750.

I asked how much it would be without insurance and they quoted me $350.

My understanding is that the insurance does not actually pay the price they tell you in your explanation of benefits.

So if it's any comfort, I'd guess your insurance wasn't getting billed on top of that. They probably paid $15 and pocketed your copay.

Some might call this "keeping two sets of books", but apparently it's par for the course here in the glorious USA.

Up until recently [0], it was common for insurers to have rules preventing health care providers from telling you when it was cheaper to pay cash.

[0] https://www.aarp.org/health/drugs-supplements/info-2018/gag-...

If it's any consolation, the insured patient payments are subsidizing the non-insured cash cost.

A famous Norwegian professor of social medicine, Per Fugelli, once told a story in a talk that has stuck with me for some reason; Per was talking to a taxi driver, and the driver told him that he was having surgery on his heart valve. Per asked if he was scared , and the driver looked at him and said "No, Per, would you like to know why? Because the surgeon who will operate me has also operated the King" (the King of Norway has had several heart surgeries through ht eyears). I think it's a nice story.

Unfortunately, most of his works are in Norwegian, but his last essay before dying from cancer was called Thank you, Norway - and good luck on your watch (Google Translate uses "god vakt", but I guess it is an idiomatic greeting to guards whos shift is starting) [0] - he was afraid the three pillars of the Norwegian society was somewhat threatened: justice, trust, freedom

[0] https://translate.google.com/translate?sl=no&tl=en&u=https:/...

It would be nice to be able to see the lowest & highest prices & other stats. I can manually find the lowest price by sorting by price but I can't seem to reverse it to show the highest price first...

Anyway, it seems that there are orders of magnitude differences for the same service.

The service 'MRI Lumbar Spine With & Without Contrast Material' has a lowest price of $210 while the closest and highest I personally could find was ~$4109.

How can there be such a large difference in price for something that, I believe, is legally & medically the same procedure?

In 2015 I did several months of due diligence in this market - price comparison for diagnostic imaging - before concluding that it wasn't feasible to build the product we wanted to build. This new law provides the data that we were unable to access (at scale) on our own.

From the data we did get our hands on, I remember seeing price differences like $200 vs $4k for the exact same procedure. The low cost provider was usually a private practice radiologist in a small shopping mall type retail location who ran a very efficient, low overhead practice. They were terrible at marketing and ran discounts for volume from certain channels. They were only open Monday to Friday from 8am to 4pm, read times could often (but not always) be slow, they handled the least complex cases and no emergencies. Cash pay up front from patients resulting in no/minimal collections. The high cost provider was usually a large University affiliated medical center who ran a less efficient, high overhead radiology department but who also, in their defense, had to handle more complex cases as well as be open 24/7 to service one or multiple emergency departments with faster read times. Lots of fighting with insurance companies for eventual reimbursement. Lots of bad debt that went to collections and had to be written down.

If you pay University prices for a simple MRI you are effectively subsidizing the ED admit who needs a complex imaging procedure in the middle of the night. If consumers start to shop for MRIs the way they shop for airline tickets - which they probably should - one downstream effect will be to remove billions of dollars of "subsidies" from the most well-resourced radiology departments in the country. If I remember correctly the diagnostic imaging market was something like $150 billion/year in 2015, and probably even bigger now, i.e. plenty of potential fat to cut.

Response time / availability is not something I considered in medical service pricing before but wow it makes a lot of sense.

For folks who don’t believe in universal medical coverage, this is part of the reason why it’s so inefficient for it not to exist.

The uninsured person going to the hospital at 1AM that requires an MRI because slipped a disc in their back still ends up getting that MRI. When they fail to pay that bill, which would be 5%-10% of their annual earnings, we all still pay for it. We just decided to layer in debt collection, anxiety, and depression onto the patient in lieu of cash.

As someone who still considers themselves a fiscal conservative, and also believes we need true universal coverage for all Americans, this seems like a no brainer to me at this point (and I say that as someone who would have not supported this in the 00s but has evolved significantly on this issue).

My takeaway from all that research was the same. Almost everyone benefits from universal coverage but the system has to incentivize patients to shop around for the optimal balance of price, quality, and convenience. This can be accomplished with an annual deductible of a few thousand dollars perhaps capped at a % of income. Without this incentive, costs skyrocket. Price transparency is a pre-requisite without which consumers can't easily shop around, so this law is a giant leap forward in the right direction.

That is the #1 most effective thing that Americans can do to reduce health care costs. #2 would be to change the standard American diet and eat healthier to reduce rates of obesity and diabetes. Almost every other proposed structural change or intervention we looked at was minimal by comparison.

There was an attempt at this with prescription drugs. Encourage patients to take generics by forcing a larger amount of cost onto the patients in the form of higher copays.

Pharma companies realized and started giving copay vouchers (still charge insurance more, but short circuit the patient incentive). When that loophole got tighter they formed charitable foundations to give the vouchers instead.

I'm not disagreeing with your points, per se. It's just amazing what entrenched interests can manage.

Do you have any studies or sources to back this up?

As I understand it, in most EU markets there's no price component, nor much of a choice component and costs haven't skyrocketed.

I lived under the French system for years, and it’s entirely untrue that there is no cost or choice component. You pick the doctors and you pay them fully out of pocket. Your insurance company reimburses you at ~80% of reasonable and customary rates. If you wind up going for inpatient care it’s different, as is the situation for those in extreme poverty. Also, you can pay extra for 100% coverage if you want, but ISTR it was expensive and not really worth it for us.

Now, when I left, the doctors and insurance companies were setting up an analog of the US system: If you saw certain doctors, they would not charge you at point of delivery and there was no co-insurance requirement. It was still new and inconvenient, so I don’t know how that’s worked out.

I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc.

> I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc.

I moved from the US to Switzerland so maybe I can offer some anecdotes here. You're basically right in that it's a slightly cheaper version of the US system. However, some things that I didn't have to pay for in the US such as calling am ambulance without riding in it or seasonal flu shots do cost money here ($500+ for an ambulance to show up in the middle of a large city...), but I think these small lapses are overshadowed by expensive inpatient treatment being essentially completely covered minus some reasonable deductibles as well as outpatient treatment that is usually partially covered depending on the insurance plan.

The positives compared to the US largely revolve around necessary and typically expensive treatment being far more likely to be covered under insurance with relatively low copays and deductibles. The downsides in common with the US are the administrative hassles of dealing with an insurance company and its own billing middlemen (e.g. a COVID test was improperly billed to me which needed to be sorted out), the large monthly premiums for most people (~$250 is typical except for those who qualify for subsidies), and the lack of clarity over what and how much of anything is covered even when the billing is done correctly.

Do I call an ambulance? Do I go in to see a doctor? Will I end up with a massive charge? I'd prefer a single-payer or completely comprehensive system for this last point alone.

Almost everyone benefits from universal coverage but the system has to incentivize patients to shop around for the optimal balance of price, quality, and convenience.

Universal coverage does not need to incentivise shopping around in a single payer system. Also, the majority of patients are not capable of evaluating quality of healthcare, nor should they be.

Any system should incentivize shopping around unless it wants inflated cost. That or discourage frequent engagement (the US consumes comparatively massive amounts of healthcare product and service with inefficient outcomes). Our present system is _designed_ to prevent price comparison and shopping around via price opacity, network lock-in, state-level artificial supply barriers, etc.

Universal coverage on par with Europe would mean we all start consuming less individually (which isn’t a big deal to outcomes but not part of our culture), or we need to have a far more competitive environment for suppliers. Either would be better than what we have today, whether insurance is public, private, or a mix of both.

I honestly don’t think price comparison can work for general healthcare, plus it would lead to huge disparities of care quality as the US has now, which means in practice a very expensive safety net for which the government picks up the tab.

Better just to go with single payer healthcare, not linked to employment or insurance, and dramatically reduce costs with similar outcomes.

Everyone wins, and those with money can still buy private care or private insurance if they wish, truly shopping around, as they have the means, education and leisure time to do so.

Also a fiscal conservative, I completely agree single-payer would be much better than what we have now.

What I think would be best though, is to eliminate medicare/medicaid, hand people cash, and get out of the way.

The high-order problem with medicine isn't coverage or insurance. It's price. There are only two ways to get price under control: meaningful competition, or government price controls (e.g. single payer). Single payer would end up like public schools: one choice for everyone, probably OK quality, but not great.

I think we could do so much more here if we just created a cash market and handed people money. It's what Singapore does. It would let doctors compete on -- even discover -- what actually matters to consumers -- wait times, when procedures take place, even how comfortable the office is. I would much rather have a market with choice and variety than one that straitjackets everyone into a one-size-fits-all system that might work for some but probably won't for others.

I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices.

It's funny. In a community where people are so focused on innovation, and startups, and choice, I see a lot of support for a national single-payer scheme. I would much rather take the collective energies of this community and apply them to innovation in this market, with meaningful choice and competition. Medicine needs more of a startup mindset. And for those roasting me about how it's different/dangerous/risky: what we have today is KILLING us, economically.

Patients would still decide where to be treated based on those factors, the only difference is the insurance is standardized. Nobody in countries with socialized health insurance seems to complain about lack of choices or any of that, and rich people in those places can still get private insurance to get their nose job done right away from a private practice. For everyone else I get the impression it works just fine.

I'm less convinced. The NHS, Britain's version of this, is constantly underfunded, and has long wait times for a variety of procedures. The Economist writes about this frequently.

https://www.economist.com/britain/2018/06/28/the-three-myths...

> I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices.

I don't think so. If providers can't expect to be paid adequately (in relation to their capital investment, research costs, operating costs, etc) for dealing with "rare (and expensive) conditions", because people don't have insurance (whether private, medicare, or whatever), just a modest amount of cash in any given patient's pocket, do you really think they'll want to stay in that market?

You’re advocating for the same system that ruined colleges: guaranteed loans.

Also coverage is also a huge deal in the US, although it may not be a problem for you specifically. Obamacare covered millions who otherwise might have stayed home instead of seeing the doctor.

The problem with US health is scoping. Insurance companies are effectively “certifying” which hospitals and doctors you can see instead of actual certification bodies.

> Obamacare covered millions

I was one of the people who lost insurance starting a new business - too rich to get subsidized (cutoff was/is >~50k/yr), too poor to pay the equivalent of a second mortgage for individual insurance because of runaway premiums on individual market post-ACA. And penalized a few grand for it come tax season until the mandate was effectively rolled back. Was more than supportive of that rollback.

It’s a risk management game for new business owners, and a big incentive for people to keep working for the man.

I never said anything about loans.

What I'm suggesting is food stamps. Everybody can pay cash. If you can't, you get government assistance in the form of a cash-like subsidy that can be spent anywhere food is sold.

It's a fast, efficient way of ensuring universality of care while benefiting from the market discipline you get from having a (mostly) competitive, cash market. Not to mention, there is no insane "food insurance" bureaucracy. You swipe the card at the checkout line and you're good.

aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems.

> If people can't pay as much, the only thing for them to do is drop prices.

Or not offer the product at all. One problem with this entire area is that "healthcare" is really not one service/product area, and it is probably a mistake to treat it as such.

To be transparent, I don't share your optimism about market solutions to problems like this in general (more about their implementation in practice than theoretical benefits) but I can see how it might help with parts of the routine healthcare. However, when you are talking emergency and major treatments, it's well into the range where direct consumer driven decisions are more likely going to mess up the incentives badly.

If you are lucky enough to have the time (often not true), most people can become reasonably expert in their own disease state and treatment options. But that is a tiny slice of what is going on in a hospital system for example, and it's completely unreasonable to expect people to become informed enough to make good decisions there. If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers.

It's worth noting that in theory this is what the insurance industry does in the US, though, but is an expensive mess. Another confounding factor is that many obvious price discovery mechanisms will be completely unacceptable to most people.

Honestly, it's a mostly faith-based argument that a cash-based market approach can find a better global solution than universal health care, at least in a relevant amount of time. It's really hard for me to see why the country should take that risk when there are well understood and well modelled approaches (albeit imperfect) that should be able to reduce costs by at least 1/2, probably more.

Why not start there?

The main thing I take on faith is that people are different and one-size fits all solutions don't produce good outcomes. We have different car brands, grocery stores, non-health insurance companies, package delivery companies, retailers, and housing options. Some people want fast and cheap. Others want to drive an hour to save a few bucks.

This isn't some technical academic point. Without a range of choices, you actually can't know what people truly want. So things don't get better. People can't signal what's truly important by voting with their wallet.

> If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers.

I don't get this at all. There are so many markets where complex, highly-paid specialists do work customers might not understand: estate/trust lawyers, auto repair, even dental care. We don't have nearly the same problems as in medicine due to this culture of treating doctors like God. They aren't. They're just a person doing a service, just like a chef or a guy painting a house.

What actually bothers me most about this whole thing is that nobody is willing to get serious about the tradeoffs their system entails. Health care in the US is failing right now. Companies are trying to stay beneath ACA limits because health insurance would crush them. My premiums are $380/month as a healthy, 36-year old nonsmoker with no rare conditions. That is INSANE. There's ever-more incentive to keep people off of W2 employment because premiums have gotten so out of control. If you take the current system, where bankruptcies are the norm, this monster is devouring almost 20% of our GDP, and every time I go to the doctor it's a major hassle, I'll come out and say that yes, maybe I'd prefer to fix that even if someone can't get a $150,000 drug anymore.

>aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems.

Umm...why not? You can't just hand-wave that away.

> Umm...why not? You can't just hand-wave that away.

Sorry, I should have elaborated. It's a city state with unusually high levels of both social compliance and government control, population is fairly wealthy and fairly evenly distributed. So - small population is a very small area simplifies logistics a ton. Especially ignoring problems related to migrant workers (it's own set of problems), most people have both high social support and some financial depth, there is also little to no housing insecurity.

It's basically unclear if you can successfully scale the Singapore model, nobody has tried. As against, e.g. , the several universal models that are outperforming the US currently, with more comparable populations etc.

Sidecar Health's website exactly what their insurance pays for a procedure/doctor-visit/Rx -> https://app.sidecarhealth.com/previewCoverage

> I don't get this at all.

I think this is why I suggested looking it as two markets. Your examples (estate lawyers, auto repair, dental care) look a bit like a visit to your GP's office. None of it looks much like some of the other things healthcare provides for us (e.g. many major and emergency procedures). And it's not like all of those markets are working particularly well currently (auto /house sales/ opticians/ etc. suck)

I don't think anyone would disagree that one-size-fits-all is the right approach, which is why nobody really tries that. What you are essentially saying is that you think is that you will get more flexibility if you open that market further, and that it will be both a better solution for more people, and not a horribly worse for any significant number of them (which is probably not acceptable here).

I'd agree with the first part, but the second requires faith - that in practice the signalling that you are talking about is clear enough (in both directions) and the response time short enough that you arrive at a better solution and in a reasonable amount of time. This is not at all clear. This isn't about treating doctors as "gods" either, they aren't able to make the systemic decisions well either, individually.

> What actually bothers me most about this whole thing is that nobody is willing to get serious about the tradeoffs their system entails.

This I agree with entirely. Two big ones come to mind - we need to have a conversation about appropriate end-of-life care and costs, and we have to be very transparent that our current level of medical capability means that there is an appreciable risk that (to a first approximation) anyone may end up with a medical condition that (a) we know how to cure or mitigate and (b) that person will never be able to afford. To me paying for these (or choosing not to) is quite different than making sure you can get antibiotics when you get strep throat.

You point out some symptoms of the problem currently, but I'm a bit curious about why you are resistant to pursue know solutions that look more like, say France (or Canada, etc.) , than Singapore. Is it just ideological? I'd rather take some known improvements and then iterate to improve rather than NIH syndrome.

I don't think the "free market" can ever truly work in practice in the medical field, except for elective procedures and visits. Sure, if doctors want to compete on giving me a low price for vaccines and office visits, etc., I can see that working.

However, any emergency service essentially has a captive audience. Most people who need an appendectomy or are having a heart attack are not in a position to price-shop. They need close, immediate care. Hell, quality probably doesn't even matter in these situations... not dying is the goal. This is where the free market doesn't work because there's no true consumer choice.

Why add additional steps, government should open hospitals and provide healthcare directly.

Why? (Seriously - you seem to be assuming the answer here.)

Would the same statement be true for food and shelter (also necessary for life)? Should the government be the provider for all food and shelter in order to avoid additional steps?

Because a person is capable of determining good produce from bad produce and make informed decisions when purchasing groceries.

The same is not true for healthcare. Even when purchasing shelter, people are not sufficiently informed to be able to make a good decision, hence the existence of electrical, plumbing, and structural codes and inspections.

With healthcare, people are extremely uninformed. The costs are extremely high. The government doesn’t necessarily need to vet the doctors’ diagnoses and prescribed remedies, but they could. So could insurance companies, which is what currently happens in the US.

This is a bit chicken-and-egg. People are uninformed about cost and quality of healthcare because the third-party payer system obscures detail (often intentionally).

Spend some time uninsured and you become a very discerning consumer.

Further, for every service that requires healthcare advocacy (often provided by family members, btw, not professionals even in existing system) there are probably >five that are commodity services (labs, prescriptions, diagnosis, imaging, etc.)

Maybe. That would have economical benefits also by lowering crimes related with lack of food or shelter (therefore releasing money to spend in other things and contributing to social peace). The plan would deserve a closer look.

The difference between an apple being stolen by a homeless and an apple being given to a homeless, is that you don't need to pay for fixing the broken window.

> How can there be such a large difference in price for something that, I believe, is legally & medically the same procedure?

I hope this never happens, but let’s say you got in a motorcycle accident and need that lumbar MRI to figure out the damage. What are going to do, get back on that wrecked motorcycle with a fucked up spine and go to that 210$ place?

They do it because they can do it and get away with it.

I see this argument a lot.

The trouble is that emergency care isn't what drives the majority of healthcare spend. What does is actually chronic conditions: dialysis, diabetes, autoimmune disorders, chronic weight conditions.

That's what we need to worry about.

And if there was a real market here, you wouldn't need to shop around because all the people that do, would enforce some level of price discipline on the market.

Think about it. For any good sold at, say, Wal-Mart, say Gatorade, there are some people that want it a LOT, even NEED it, while others are more on the fence. There's only one price on the shelf and it's calculated to get a lot of people buying. So in effect, the people who are more indifferent (want it less) are actually doing a pretty significant service to the people who want it a lot, by guaranteeing the price will be set low for everyone.

There's no reason something like this can't apply in healthcare.

>How can there be such a large difference in price for something that, I believe, is legally & medically the same procedure?

If no one publishes their prices how do you set yours? 2 dollars? 2000 dollars? 2m dollars?

I am pretty sure the providers and insurers know exactly what everyone is charging. It’s the patients that are being kept in the dark.

Like any opaque market, bigger players will have more info, but I doubt anyone will share information as its collusion (maybe illegal) and also advantages either your negotiating opponent or your competitors...

Exactly. Small payers are actually pretty hungry for this data. Generally, big payers are more privy to market rates (by paying for datasets, owning clearinghouses, etc).

When I needed a similar non-emergency procedure (cervical, rather than lumbar, MRI), my neurosurgeon, at a large, university-affiliated hospital, referred me to the in-house radiology department.

Within a day or two, I received a phone call from some department at my health insurance provider telling me "Hey, we see that you are going to get an MRI; did you know that you can get the exact same procedure at providers A, B, and C, for a lot lower cost?" They did this even though the hospital's radiology department was in-network.

In this case, the cost difference was similar to what's noted here - about $4,000 vs $450. Since the insurance company was paying most of it, aside from my copay / share of cost, they were motivated to provide me a little transparency.

To be honest, as a patient, I would have preferred to get the MRI at the hospital; their facility was nicer, cleaner, more modern, and there was better data integration for getting the results to my neurosurgeon and keeping them as part of my holistic medical record. Nonetheless, I went to the cheaper provider.

I realized over the past few years that there is no "natural" price for anything. It's 100% set by competition.

Economic research confirms this. Mergers result in higher prices due to less competition.

What we need is way, way, WAY more competition in healthcare. 10x as many providers, 10x as many clinics, with prices posted on the wall. When they start losing business, they'll notice.

There will never be 10x as many providers due to the AMA and lobbying. Existing interests don't want to see lower prices and competition.

If this was possible, I'd agree with you. But the reality is that the best we can hope for is single payer.

I was arguing with a doctor friend recently about the AMA. He's on team New York Times, "knows" the Koch brothers are Satan incarnate, "knows" Trump owes Russian oligarchs money, etc.

It just didn't register that the AMA is the sixth-biggest spending organization on DC lobbying [1], right behind Blue Cross Blue Shield (an insurer) and the American Hospital Association.

People worry about the NRA and all kinds of other stuff. They should really get mad about how outrageously the medical industry lobbies (as do the realtors), and how much they've managed to extract from ordinary Americans. It's an utter coup of PR that people aren't rioting in the streets about this. Everything about the medical industry -- licensing, high physician salaries, etc. is rigged to be good for insiders.

[1] https://www.opensecrets.org/federal-lobbying/top-spenders

I think you're right. The issue with these services is that they're extremely local. Really, only cities will likely really have much competition. That relies on there being separately owned facilities. And even then there is the issue that 2-3 providers never really compete even if they're not colluding...

I honestly think that free market healthcare is doomed to failure. The information a-symmetry, the size of hospitals compared to populations, localization, the degree of specialization, strategic nature of services, and the social externalities are just too great to ever really have a market. But that's just me on my soap box.

Hopefully transparent pricing will do some good at least. I wonder if requiring insurers to share savings in cash would further encourage people to shop around (eg going to the place 4h away to get a 2k MRI instead of a 4k MRI means you get say half the saving [1k] back from your insurer)...

Yeah, actually I can attest that a lot of our hospital clients have no idea what the hospital next door is charging / getting paid by insurance. So, a lot of price setting is guessing. It's often not cost-based. And often, negotiations will arbitrarily shift high prices over to one service type, eg Blue Cross will say: "Fine, if you want to get paid that much for knee replacements, we get a lower rate for bariatric surgery." So you'll find weird price discrepancies within the same provider.

Sidecar Health's website publishes exactly what their insurance pays for a procedure/doctor-visit/Rx -> https://app.sidecarhealth.com/previewCoverage

Thanks for the feedback! We'll be improving our filter/sort here in the coming days and we'll take this feedback into our plan.

My searches so far show insane differences between insurance rates and cash rates. The cash can be 5-10x higher than what the insurance company pays.

It seems like a clear case of systemic fraud to me. Am I missing something?

Also I am not able to find any fundoplication or LINX (43284).

Many hospitals don't discount from their list price for self pay. Medicare pays ~10% of list price. So, for example, if there is an insurance rate set at "130% medicare" (common to have a coefficient between 1 and 2), then yes, you'd still see many cash rates that are 5x insurance. However, many hospitals also listed Managed Medicaid insurance rates. These are generally 3-5% of list price & look for similar to normal insurance plans. So, what you're seeing may also be comparing a Medicaid rate to a very high cash rate.

Will add 43284 & other gastro procs shortly. Thanks!

Sometimes the cost is bigger than the cost in a different country plus the plane ticket.

I guess you could roll the dice and hope the for best but you will lose your ability to sue the hospital for malpractice if they mess up.

Maybe there is a chance that insurance could be enabling malpractice? I'd have to get hard data on this to make a determination but I'd wager that most reputable medical professionals try to avoid malpractice regardless of country.

The alternative is often to not have the procedure at all.

You're making a lot of assumptions here that an out-of-country hospital would be of questionable quality and not have medical malpractice laws.

Just because other countries medical & legal systems are different than the US doesn't mean they are inferior.

The GP was talking about losing your ability sue for malpractice not implying that every other country has inferior medical or legal care.

A country can have a fine legal system for locals that's difficult or prohibitively expensive to access for non-citizens living outside the country.

One of my businesses refuses to serve Americans simply because they have a habit of reaching for the legal system if they aren't happy with the service.

All the Americans end up going to my competitor, who is currently in the midst of three lawsuits which will probably sink the company. Two of the lawsuits are with clients I turned away simply because they looked likely to sue!

You can bet that as an American, you will pay substantially more than a local for many services simply because Americans have a reputation for this sort of stuff, and local businesses don't want to take the risk.

I really wish there was some kind of certificate saying "I have never set foot in a courtroom, threatened legal action, or hired a lawyer".

And then the hospital can't sue you if you can't pay the absurd bill?

It isn't the people with legit complaints.... It's the people who do something foolish and then try to sue someone else blaming them...

If I rent you a jetski for an hour, it isn't my fault if you drive over your child with it... It's a jetski. It's dangerous. Don't expect someone else to pay if you mess up.

In a country with socialized medical care, someone else does pay.

Here in India. You pay upfront. No payment = no surgery.

That's why I don't let black people into my restaurant. Statistically, they're more likely to commit a crime once inside, so I don't want to take the risk. All the black people in town end up going to the restaurant down the street, who had their register robbed one time by a dark-skinned fellow that I turned away because he sure looked suspicious! I sure hope they've learned their lesson by now.

You can bet that as a black person in our town, you'll pay substantially more than white folks, because most of us understand that black people have a reputation for this sort of stuff and general trouble, and we don't want to take the risk.

I really wish there was some kind of certificate to let us know which ones are the docile blacks...

(Note: It should go without saying that this is a tongue-in-cheek response)

I'd be all for banning discrimination based on nationality. But we need to start with the biggest discriminators - governments. Why is an American allowed into America, but a Syrian isn't?

Theta a terrible idea. Why "start" somewhere?

Should we abuse and enslaved more people just because someone is abused or enslaved elsewhere?

It's a poor response. Nationality is tied to legal system. For example, if a product injures me as an USAn, I need to sue to get my bills paid. As a European, I can simply get public healthcare.

If I'm a USAn doing business with a private company in a foreign country, that's not relevant. OP is using population-level trends to influence develop his bias towards individuals.

Even the best hospitals make mistakes, malpractice is not just some cudgel used to beat good doctors over their heads, and America has some of the most comprehensive malpractice law in the world.

That said, if I'm wrong about that I'm interested in learning more.

> legal systems are different than the US doesn't mean they are inferior

Yes. Indian legal system is very inferior compared to USA. My family is fighting a garden variety land dispute case for over a decade. I cannot even imagine someone successfully suing a doctor here for malpractice while living in USA.

I have never anticipated a medical procedure, emergency or otherwise, and considered "my ability to sue for malpractice if this goes wrong". I just don't believe this is a consideration for the actual patient, even if it was relevant (example: Canada with universal public system essentially has no malpractice lawsuits).

From this data, I could do that by going to another state.

The U.S. healthcare system is built around the idea that everyone has health insurance. Obviously, that's not a valid assumption at all, which is one of many reasons why it's such a problem.

Insurance companies each negotiate a rate for various services with hospitals. People pay different rates depending on the insurance they have, due to these different negotiated rates.

This creates a perverse incentive where hospitals want to list their "cash" price as being higher than the negotiated rates, otherwise insurance companies will come back to negotiate their rates down to the obviously lower cash price.

In reality, it's usually surprisingly easy to get hospitals to give significant discounts if you tell them you're without insurance and you'll be paying in cash. Patients without insurance can often negotiate their bills down to a fraction of the original list price by simply calling in and telling the billing office they don't have insurance.

It's obviously not a great system.

It's a criminal racket.

You have no position to negotiate and I have never got them to budge. I have tried and gotten pretty angry about it.

Short-term insurance is a waste of money because the rates did not appear to be negotiated at all. They paid 5% of the bill and stuck me with the rest.

The only reason to actually pay your bills is the hospital might eventually sue you. Its messed up.

If you don't pay, they'll budge eventually. Unless you're rich, maybe, but then paying more is socialized health care.

Unfortunately not my experience -- went to nearest ER for sudden and agonizing abdominal pain, got some basic pain meds, got a CAT scan to diagnose pneumonia, was sent home within a couple of hours (lots of waiting).

Turned out the hospital was not in network, they charged me $15,000 (including $10,000 for a "level 5" ER room stay, which is twice the most expensive price listed on the OP's website and is 10x the local average price for that service, despite the fact that my experience could not possibly have been Level 5 service). Eventually they just sold the debt to a collections agency. I tried to fight but they didn't seem to care, and why would they? They already sold the debt!

What country lets non-citizens just walk in to use the health care system?

Thailand.

I assume they were referring to countries where you can pay out of pocket for care at private clinics and hospitals, as a visitor. It's called medical tourism. India is a major destination.

The whole European Union for EU citizens with an EU health card.

I actually can't think of one I've visited that doesn't.

Brazil

Norway, Poland.

I'm a UK citizen, resident in Norway, who has visited Poland on business many time.

I stayed a night in the Krakow Neurological Institute somewhere between fifteen and twenty years ago, cost me about 100 USD. The ambulance that took me there was free.

Wow, you might already know this but in the USA people decline ambulance trips because the cost out of pocket can break them financially. A ambulance helicopter trip (which people are usually not in a position to decline) costs roughly 40,000 last time I read about it, a lot of people crowdfund to pay for this.

25 years ago I was hiking on a mountain in Switzerland with a group of people. Descending, a guy lost his footing and broke his leg. So there we all are, a few hundred feet from the summit. We could see the town below us, and the hospital there. Someone had a cell phone registered in the UK. We talked to a UK operator who connected us through to the hospital in the town below. They wanted a credit card before sending up a helicopter and doctor ;) If I don't have this completely wrong in my head, I think it was $2500 on unfortunate hiker guy's Amex.

A few minutes later we saw the helicopter lift from the hospital and head straight towards us. Down came the rescue equipment and Dr Bruno, who told us not to worry because "We do this all the time!". 10 minutes later he was ascending with the patient.

I learned two things: Doctors in Switzerland really do do this stuff all the time, and always have hiking accidents near well-equipped medical facilities that aren't trying to totally screw people over.

I'm pretty sure it was the best $2500 that guy ever spent.

> What country lets non-citizens just walk in to use the health care system?

Almost all.

Non citizens just pay a fee or are reinbursed later by their insurance or healthcare system. In many cases citizens from country 'A' can use healthcare in 'B' as long as their own citizens will be granted the same treatment in exchange when visiting 'A'. It depends on the treatises signed between the two countries.

Allowing foreigners to use the health care system for free is sometimes allowed (or even encouraged) if that protects the interests of the country.

Why are the prices so insane? Where do the money go? I'm from Eastern Europe so of course the prices would be different, but by an order of a magnitude at the minimum seems strange.

- paying for services for people who don't have/can't afford insurance.

- medical malpractice insurance -> legal system

- big pharma/med devices industry

You should add

- doctors are paid higher in the US than in another countries

- billing staff overhead because of the insane insurance system

- highly paid hospital administration

- lots of middlemen that stay invisible because there is no price transparency

- shiny new buildings that are built by friends of the hospital administration

Look up the salary of your local hospital president. In my medium town of (Pop 200K) they pay him $980k per year. That is an absurd salary for a relatively small hospital!

How do I look that up?

AFAIK, certain non-profits are required to report the salaries of their ten highest paid employees.

Doesn't mean it will be easy to find, but you might be able to find it that way.

But this is not information the hospital would share w/ you w/ great enthusiasm, obviously.

... Add also the medical equipment prices inflated by layers of distributors.

Big pharma?

Big pharma has actually reduced the hospitalization costs over the past two decades.

Edit: can someone explain downvotes?. How is big pharma increasing hospital costs?

please take a look at this, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669633/

"The major empirical finding from this research is that medication use by Medicare beneficiaries is significantly negatively associated with hospital spending. Moreover, the cross-effect is quite large: each additional prescription drug fill reduces hospital costs by slightly more than $100 or about 5 percent measured at the mean level of Medicare payments in 2000 for inpatient hospital services for study subjects. "

Plus

- Gold plating everything to avoid getting sued.

- Inflated medical school costs

- the price of a huge bureaucracy for billing people, chasing them, disputing it, agreeing rates with insurers, renegotiating rates with insurers, applying the right discounts, billing a dozen different state and federal programs for various bits, those being disputed, managing all that etc.

-Disposable everything, priced at a premium

I moved to usa from a poor country to work at a hospital. I was shocked by how awesome, clean and luxurious everything looked. Top end fancy hotel in my country would look like a slum dwelling compared to a hospital in USA.

Going from the USA to a hospital in Thailand is a similar experience. Everything is so clean!

Don’t forget AMA antitrust violations but curbing the number of doctors that could get into the system.

Underrated answer, but it isn't an anti-trust violation when they have permission to accredit med schools!

To be clear: I totally agree w/ you that the AMA is a cartel.

Everyone hates pharma (not entirely without reason!) but all drug spending is about 10% (slightly less) of US health care spending.

If you spent $0 on drugs next year, we would not save that much money.

If you want to cut spending, you need to cut spending on doctors and hospitals.

If you want sources for these numbers, here is the National Health Expenditure summary from the Centers for Medicare and Medicaid Studies:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

It is a sliding scale. American prizes are 3 times more than private clinic in Helsinki, and again those are 3 times higher than in Lithuania.

For example ultrasonic diagnosis of your frozen shoulder is 600 Euros in USA, 200 Euros in Finland and 80 Euros in Vilnius.

This issue is relevant, because European healthcare wont fix your shoulder, because it is a "cosmetic problem" and will disappear on its own in a year or two.

Why this was downvoted? It would be nice get even some clue why this is happening so often on totally trite statement of facts.

It's simple: waste. Everywhere.

There is no incentive for doctors to be efficient so they aren't. They order too many supplies, do too many procedures quickly (when doing them slowly would be fine, and cheaper, etc).

Price discipline is like gravity. It affects everything. In most American businesses subject to market forces, there is an enormous push to optimize every single little bit of the business to control costs.

This force simply doesn't exist in healthcare.

Market forces aren't exactly prevalent in nationalized healthcare systems like the ones seen in Scandinavia either, and they keep costs way down compared to the US.

>Why are the prices so insane?

Because up until a few weeks ago, people weren't allowed to see what hospitals charged until AFTER getting their bill. It was a ridiculous system, and I'm glad Trump got rid of it.

Suggestion: I hope I didn't completely miss something, but the site seems to put average prices for procedures all over the place when the median price would actually be much more informative to somebody searching for a provider. Looking at a few procedures, the prices seem to have significant outliers, which exacerbates this.

Thanks, we're working on figuring out the best way to represent those and maybe making them more location-specific. Even with median prices, it doesn't always make sense to show a country-wide median since there is a huge difference in price ranges between markets. A super high price in Nashville might be a super low price in Los Angeles, for example.

This is great (and totally unfortunate that it needs to exist in the US), thanks for building it.

One issue: it looks like the search is not respecting the zip code for me if I change it. For example, if I search for a procedure using the zip code the site auto-populates, my results are great. However, if I change the zip code to my actual neighborhood here in NYC, I'm seeing results from all over the country.

Thanks, I'll take a look! If you don't mind, would you mind dropping me an email at adam@turquoise.health with the zip code you are trying?

It's always fascinating to see that even compared to prices you pay as a self-paying patient in Germany (which are already 1.5x - 2x higher than what the "public" insurances, ie. 85% of the population, pay for the same procedures), the prices in the US are about 5x to 10x higher. The standard of care seems to be quite comparable if you look at outcomes, so there must be huge inefficiences in the American system (doctors in Germany are consistently ranked as the highest paid academics, so I guess it cant be doctors' salaries alone).

I don't believe any medical professional in Germany has wage exceeding 150k EUR yearly after taxes - doctors in the US sometimes have multiples of that, coincidentally 5x to 10x more is not unusual.

I’m sure German doctors don’t have oodles of student debt too.

Yeah, that for sure.

It's true that US doctors are paid more (although the gap isn't as big as it used to be). However, pay for US doctors makes up a fairly small portion of overall US medical expenditures (less than 10%). So, you could ask every doctor to work for free and not significantly change costs.

There’s a similar (but smaller) differential for other medical professionals too. But more generally, when I’ve done high-level comparisons of medical spending between the US and Western European countries, it seems like every single cost element is more or less proportionately higher in the US. It seems like basically everyone is spending money in roughly the same proportions, including on things like doctors’ salaries - everything is just scaled up by ~40% to ~100% in the US, depending on which country you compare it to.

And doing so more frequently in the US, so cost is higher but so is rate of consumption, particularly of services and products that make us feel like we have more mastery over outcomes but in fact do not result in better outcomes on the whole.

>pay for US doctors makes up a fairly small portion of overall US medical expenditures (less than 10%)

That is likely too low.

The Centers for Medicare and Medicaid Services provides a National Health Expenditure estimate annually. [1]

Physician and clinical services represented $772 billion out of about $3.8 trillion, so more like 20%.

Hospital services are the other big one: about $1.2 trillion.

US physicians are paid terrifically relative to their counterparts almost anywhere else, this is especially true for specialists.

In fact, physicians represent about 15% - 16% of the top 1% of income earners in the US. See table 2 from this paper: https://web.williams.edu/Economics/wp/BakijaColeHeimJobsInco... which was written using tax return data, not, e.g., self-reported income data.

[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

"Physician and clinical services" includes far more than pay for US doctors -- it's the entire costs for "services provided in establishments operated by Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.), outpatient care centers, plus the portion of medical laboratories services that are billed independently by the laboratories". Doctors do not get even close to all of that money paid to them.

> In fact, physicians represent about 15% - 16% of the top 1% of income earners in the US.

This may be accurate, I'm unsure, but it wouldn't change that if US doctors were paid the same as their European counterparts, it would not make a truly significant change in overall US medical spending (this would even be true if doctors did actually make up 20% of medical expenditures, like you assert earlier).

Just throwing some data, average general practice doctor is 150k$ in US vs 61k$ in germany.

https://www.payscale.com/research/DE/Job=Physician_%2F_Docto...

https://www.payscale.com/research/US/Job=Physician_%2F_Docto...

I believe that doctors in the US get paid more than in germany, but 60k seems very very low. Teachers have an income in that range....

Edit: Looking at some german articles, maybe they did not convert from eur to usd, ~80,000-100,000$ (depending on expertise etc) seems more likely for a dr working at a hospital (which is still low imho compared to US salaries...).

https://www.arzt-wirtschaft.de/wie-hoch-ist-das-gehalt-bzw-d...

I think the difference in wages narrows down with specializations. I linked just the "general practitioner" because I couldn't find an average including all the specializations.

And furthermore you have to differentiate between "assistance" doctors (~82k $) and "chef" doctors (~336k $). (I don't know the comparable titles in the US system)

Both values are taken from the parent's article and converted using Google. Of course, mostly without serious student debt

You have to keep in mind that med school and the equivalent of premed in germany is completely free. Of course that does not make up for the pay difference completely but it changes the perspective quite a bit imo, since med school in the US is extremely expensive. Additionally I could totally see doctors being ok with less pay for the trade off of living in a more fair system. Coincidentally I know one expat here that specifically does not want to return to the US to become a doctor there for that very reason. She specifically does not want to move back because she feels the healthcare system in the US is unfair and she would be profiting off of that system.

That's good, doctors should be paid more. 15 years for a license.

I don't believe that salary income is the complete picture for physicians in the US. There are still a lot of doctors who are also "insider investors" in clinics, diagnostic equipment, and other medical businesses.

That’s a terrible source, $150k is laughable for the US. Maybe for a part time doctor working 2 or 3 days a week.

This is more accurate:

https://www.medscape.com/slideshow/2020-compensation-overvie...

Is this getting downvoted for saying German docs don't make more than 150k EUR or that US docs sometimes make multiples of that?

Yeah surgeons make multiples https://www.physiciansweekly.com/2018-physician-compensation.... That doesn't include profits from owning their own biz.

not 100% sure on this, but don't most doctors in other countries go to medical school for free? Whereas US doctors are going into 3-400k+ debt.

Capitalists are expensive.

I imagine it's on account of all the administration and intermediaries.

Probably some of it but I suspect the lack of limitations on services rendered plays into it as well. If someone in the US wants to see specialists 50 times in a month due to munchausens then they'll just be charged their co-pay each time (in most insurance plans). In Germany I suspect they'd not be allowed to book appointments anymore or would require a gatekeeping referral. Same with expensive drugs that don't help outcomes but are advertised to patients and doctors.

Thats not right. You can easily get an appointment in Germany, even multiple times. If you have a referral, you usually get an appointment earlier than people who directly went to the specialist. However, if you have acute pain you will quickly get an appointment on the same or the next day.

Source: Me. just made the second appointment with a specialist within a week thanks to pain, appointment is tomorrow

In the US on self-referral plans (60% of health plans) you can get an appointment without any acute symptoms and with no delay versus a referral. I'd say that's a fairly large difference in ease of access without probably any impact on patient outcomes.

> In Germany I suspect they'd not be allowed to book appointments anymore or would require a gatekeeping referral.

This is the kind of comment that immediately classifies the commenter as never having lived outside the US and/or not reading anything but US news sources. And with the wilful blindness to how exactly those gatekeeping referrals are present in most every single healthcare plan in the US.

>And with the wilful blindness to how exactly those gatekeeping referrals are present in most every single healthcare plan in the US.

This is only required by HMO plans which cover around 40% of the US population. PPO plans don't have such a requirement.

So please don't call other people willfully blind when you yourself make broad factually incorrect statements. Pot please meet kettle.

edit: Also my statements about Germany are based on comments Germans have made on hacker news regarding their own health plans. So you should really go yell at those Germans for not knowing how their own health system works.

It's not. There's a good breakdown that compares what drives healthcare spending between the US vs Germany (and others).

https://www.healthsystemtracker.org/brief/what-drives-health...

The vast majority of the difference comes from just the raw cost of inpatient and outpatient care. Even if you were to completely zero out the administrative costs per capita, you'd hardly make a dent in bridging the gap.

>raw cost of inpatient and outpatient care

I am interested to understand what makes the "raw" costs so wildly different.

When my son had an infection in germany, we went to the equivalent of pediatric urgent care and after seeing the nurse, having bloodwork done and a few different 15 minute sessions with the physician we came to the end of the visit with the doctor, they apologized that we had to be charged the full uninsured rate and that a bill would be given to us later that we could use to have our insurance (they could not bill our insurance internationally.) We paid the 50 euros and asked what the total amount would be, assuming that was the co-pay. There was a lot of confusion because the 50 euro wasn't the copay -- it was the full-freight amount. Getting a single 15 minutes with a doctor, let alone the prep with the nurses and bloodwork being rushed would be far more than that in USA.

> I am interested to understand what makes the "raw" costs so wildly different.

In the US, hospitals lose a lot of money on patients who don't pay at all or pay pennies, and in order to not make a loss at the end of the year they charge those who can pay more money.

Also, insurances have an incentive in having hospitals set high "sticker prices" because then they can claim "higher savings" for their members.

Contrast to that, in Germany as long as a patient has any insurance (and 99.9999% of Germans do) the hospitals and doctors will get their services paid (so no need to overcharge for financial reasons), and both the mandatory insurance scheme and the private insurance companies pay fixed, government-regulated fees (https://de.wikipedia.org/wiki/Einheitlicher_Bewertungsma%C3%... for the government insurance, https://de.wikipedia.org/wiki/Geb%C3%BChrenordnung_f%C3%BCr_... for the private insurance system).

Uncompensated care (includes unpaid and forgiven charges) is in the ballpark of 5% of costs, according to hospitals themselves.

> I am interested to understand what makes the "raw" costs so wildly different.

There are a number of reasons. One big one is simply that doctors in the US command a much higher salary than their counterparts elsewhere in the world:

https://economix.blogs.nytimes.com/2009/07/15/how-much-do-do...

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

Another big reason is that the US is unique in that it's one of the only countries in the world where you get your healthcare through your employer. What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. Employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.

Now, if you take this behavior and combine it with the fact that health insurers' profit margins are capped by law by percentage, insurers pay more for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in the mother of all local optima.

Disclaimer: I work on health pricing in the US and sometimes adjust claims myself.

> doctors in the US command a much higher salary than their counterparts elsewhere in the world

Yes, but salaries are also linked to huge debts to pay in their first years, a permanent state of fear to be sued by negligence (losing their license and seeing their only possibility of income vanished). It seems that suicide and depression are too common among young students. They also work too many hours in irregular schedules (working in sundays, holidays or passing one on each three weekends at the hospital is not uncommon. This will add a lot of stress for parents with small children trying to having a normal life. And is a emotionally charged work.

... So either you provide a particularly high reward in form of a golden salary, or perhaps nobody would wanted to be a doctor.

Now you're starting to follow the thread to the root cause: onerous medical licensure and onerous medical university accreditation.

In the US, the barrier to become a doctor is higher than it is anywhere else. Nowhere else in the developed world are you forced to do 4 years of undergraduate study unrelated to medicine, followed by 4 years of Medical school, followed by 4 years of residency.

Also, one doesn't require huge debts to pursue a PA or NP degree, but many States disallow PAs and NPs from practicing basic medicine.

Not everyone needs to go through the same level of schooling as a brain surgeon.

That's what I find so depressingly hilarious about the US vs the rest of the developed world [1]: that even when they super-apologetically hit you with the full, no-mercy price, it's less than what you'd way with (already overpriced) insurance in the US.

[1] Well, also developing, but super-low prices aren't as surprising or embarrassing to the US in that case.

If you think about it, you just weren’t actually charged for what you used.

If what you did were reflective of the doctor’s hourly rate, that doctor would be making around $150,000 usd/year.

And that’s ignoring the costs of every other aspect of the overhead.

The cost is being born some other way.

How can that possibly be true?

How can in/out patient care be so vastly different in cost?

Middle men. Lots and lots of middlemen.

That figure cuts out the middle-men by breaking out administrative costs.

Do they ever try to break down why IO care is more expensive? Cuz that’s a very broad and vague bucket.

> The vast majority of the difference comes from just the raw cost of inpatient and outpatient care.

Question: What do we mean by "inpatient and outpatient care"?

Inpatient care refers to any treatment where the patient is required to be admitted to a hospital or health care facility facility. On the other hand, the OECD defines outpatient care as care that "comprises medical and ancillary services delivered to a patient who is not formally admitted to a facility and does not stay overnight." Thus, studies like this try to break out "inpatient and outpatient care" as an attempt to represent the "real" service in question, while isolating things like administrative costs.

Inpatient: services provided by a hospital, after patient is admitted. Outpatient: services provided in other settings

I think outpatient care mean you don't stay in the hospital overnight. So you could have a surgery and leave within an hour in the recovery area and that is outpatient.

What does "raw" mean, in this circumstance?

Looking at the article, it's pretty hard to understand what what's actually costing more. "Inpatient and outpatient care" is a pretty enormous bucket and probably accounts for a whole lot of salaries, services, and such of pretty much any job title with "medical" in it.

Admin, does in fact represent the largest % difference... but it's not clear what's grouped into it. I assume it means government departments, insurance firms, external legal/finance services. I don't think the data refers to a salary-bysalary breakdown of costs.

Sometimes it's best to look at these things from the ground up. Doctors, nurses. How many? How much are they paid? Is the diff more or less than mean diff? If no, move on, If yes, dig deeper.

You really can't even rely on price data to tell you much. Most of these markets have a broken or absent price system. The underlying answer though, inevitably will likely be "because they're run differently."

This is useful - as a starting point.

I want to be able to make a case for a single payer system in the U.S., but I think to be effective it's a comparison of costs and outcomes that needs to be had. In the data linked above, we're told that the 'inpatient and outpatient care' is significantly higher than in 'comparable countries.'

I believe it. But isn't 'inpatient and outpatient care' just about .. everything that goes into a health care system aside from the paper pushing and insurance pieces? And are hospitals really breaking that stuff out ?

Someone in favor of the U.S. system would say, ah hah, that's because we in the U.S. have access to better care, and more sophisticated technology, than in France or Germany, and also we don't have long waiting lists. I don't know the technology claim, but I've seen the wait list claim and I do think it's true when comparing the U.S. with Canada or the UK (the latter two have long waits for essential surgeries compared to the U.S.)

How would one counter this claim?

You're right that it's a useful starting point, but I think that it's even more complicated than "single payer is better".

First of all, it isn't obvious that single payer is the best system, because there are many countries in the world that have exemplary health care systems that are not "single payer". You cited Germany as an example, but Germany doesn't have a single payer system, it has a public-private mix. It's a universal multi-payer system. Netherlands has a purely private universal healthcare system, Switzerland has a purely private universal healthcare system, Australia has a public-private mix (44% choose private), Singapore has universal catastrophic coverage but everything else is driven by savings accounts and private insurance among the upper-middle class, etc etc — Belgium, South Korea (technically "single payer" but only covers 60% of costs, private insurance fills in the gaps), Japan, etc.

From where I sit, the most apples-to-apples A/B test of single-public-payer vs private insurance is actually being run in the US, as we speak. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare, also cover Part D prescription drug benefits, and often include supplemental benefits that Original Medicare doesn't already cover. There are some interesting findings so far:

- 39% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly, that we expect by 2025, more seniors to be on a private plan than the public one. There's also great variance by State. In Florida, Pennsylvania, Wisconsin, Michigan, Minnesota, Oregon, Alabama, Hawaii, and Connecticut — nearly 50% of beneficiaries are on Medicare Advantage. By 2022, we expect more seniors in those States to be on a private plan than a public one. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...

- For most beneficiaries, Medicare Advantage costs about 39% less than Original Medicare. https://healthpayerintelligence.com/news/medicare-advantage-...

- Medicare Advantage plans are, on average, of higher quality than the public "Original Medicare" https://healthpayerintelligence.com/news/medicare-advantage-...

- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan. https://www.commonwealthfund.org/publications/issue-briefs/2... From this same research, public "Original Medicare" is still cheaper in rural areas, but not by a whole lot.

So to make things more complicated, we're not just talking about whether "Medicare For All" is better than the status quo, we also need to litigate if private-insurance driven "Medicare Advantage For All", is even better.

> (the latter two have long waits for essential surgeries compared to the U.S.)

References?

"Wait times for cancer treatment -- where timeliness can be a matter of life and death -- are also far too lengthy. According to January NHS England data, almost 25% of cancer patients didn't start treatment on time despite an urgent referral by their primary care doctor. That's the worst performance since records began in 2009.

And keep in mind that "on time" for the NHS is already 62 days after referral.

Unsurprisingly, British cancer patients fare worse than those in the United States. Only 81% of breast cancer patients in the United Kingdom live at least five years after diagnosis, compared to 89% in the United States. Just 83% of patients in the United Kingdom live five years after a prostate cancer diagnosis, versus 97% here in America."

(https://www.forbes.com/sites/sallypipes/2019/04/01/britains-...)

Yes, I know Forbes has a bent. And I'm generally in favor of single-payer options and not defending the U.S. However I have seen the Wait Time stat over the years in the context of cancer patients, and this is one data point. Canada is apparently worse.

> live at least five years after diagnosis,

Five year survival rates don't give you much information, because the US engages in massive over testing. You need to know all cause mortality, and the US does worse here than the UK.

The US over tests people and over treats cancer; that costs a lot of money and isn't pleasant for people but it doesn't make them live longer.

If hypothetical Beth dies age 82 does it matter if she is told she has cancer at age 75 or age 79?

I'm always willing to learn more - do we have a one-stop-shop apples to apples comparison of U.S. vs. UK and other countries' healthcare models with stats and explanations, one that is free from strong biases ? I struggled to find a non-political, but still meaningful comparison data site online via Google.

Given that inpatient + outpatient = 100% of the category, I have to agree. Lumping the cost of "Medical Care" into a single metric in a breakdown of spending on, well, medical care, doesn't offer much insight. Showing exactly the same data in 4 different graphing methods doesn't add anything but clutter. The lack of effort honestly makes me question this organization's mission.

I think the most useful bit is the reference to the OECD data source. For those not already aware, OECD has far more detailed data available to browse [0], and heaps of more informative and competent presentations [1].

[0] https://stats.oecd.org/

[1] http://www.oecd.org/health/health-expenditure.htm

The "administrative costs" in that analysis are misleading. "Administrative costs include spending on running governmental health programs and overhead from insurers but exclude administrative expenditures from healthcare providers." I don't think the blue bar is representative of the "raw cost" of care.

This study says over one-third of all US healthcare costs are administrative.

https://www.reuters.com/article/us-health-costs-administrati...

Also lack of shame and, greed.

Physicians and hospitals have 2 of the most powerful lobbies in the US and have previously gatekept the doctor profession.

AMA (American Medical Association) is known to play games to limit the supply of doctors, so they can keep salaries high.

http://www.econ.yale.edu/seminars/strategy/st03/nicholson-03...

Do you have a different link? The file is missing

this podcast episode has an excellent breakdown of the healthcare pricing system in the U.S.

https://econtalk.simplecast.com/episodes/keith-smith-on-free...

Everything is inflated the whole way in the American system.

Universities overcharge in the US. The medical education costs upwards of $800K if you include the cost of lost opportunity had you gone into a different field and worked those years instead. So doctors need higher salaries. That, combined with idiotic market dynamics around medical supplies, means that all medical costs are higher. That in turn means everyone absolutely needs insurance or risk personal bankruptcy.

You can't waste money on the scale of the US system by simply paying doctors too much. Rather, you need to hire entire departments of nonproductive people - eg billing and administration. When you zoom in, most of these positions look like a necessary function, but systematically they don't need to exist. Take for instance a "nurse navigator", whose entire job is to deal with insurance company rigmaroles - as a patient you're extremely thankful to have them, but their position is actually only necessary due to a corresponding insurance company department (that you're also paying for!) trying to deny you care.

The ultimate problem is this planned economy mandate of "full employment". It is in no individual's interest to declare that their own job is counterproductive, otherwise they'll starve. So they hang on performing in their own little niche, sucking resources out of the system so they personally can continue living a dignified life. We're stuck in a paperclip maximizer, and the healthcare industry is one of the best small-scale illustrations of this.

I believe a reform of the healthcare system should include paying for medical school. Let's offer a deal: You go to med school for free, then you work for the government for a decent professional salary.

You don't need the government to solve this problem, they helped create the problem in the first place. You need to reform your political system to actually make it work.

Near as I can tell, reforming the political system and changing government policy are intertwined to the point where they amount to the same thing.

US medical education length is insane. Get an undergraduate degree (pre-med). Then go to med school. Then a residency. Then you can practice.

Other countries do just fine with much less.

Indeed, and I think we can also make better use of the "lesser" medical degrees as well. For instance I get most of my primary care from a nurse-practitioner or physicians-assistant. My parents' most beloved primary care "doctor," who is an absolute superstar, is a nurse-practitioner.

Maybe there could be some kind of a continuous work-and-training ladder, where you start as a NP, and move your way up as you get more training and practice. Or you can stop whenever you think you've reached your desired level.

Those are "sticker prices", the opening for negotiation/haggling.

Do you think that is a good way to provide healthcare?

There's a bit of a lopsided leverage situation there...

Saying German doctors are "the highest paid academics" isn't really useful information. How much are they paid? Is it comparable to an American physician? German docs can be the highest paid academics in German by a factor of 10, but if American docs make 3x what any German doc makes it's kind of a moot point.

To do a real analysis you'd need to see a breakdown of where the money goes. What percentage is to a physician's salary, hospital overhead, insurance premiums, etc. for both countries and see where the big disparities are. My guess is, everything is more expensive on the US side, including salaries, and adds up to the big difference in price.

I think a lot of people are missing one key difference. Healthcare in EU is based on solidarity system where every citizen pays a percentage share of his monthly salary to the medical insurance. So if you earn more, then you will also pay more medical insurance - but you will get the same treatment as others (unless you have some fancy private insurance on top of the regular insurance). So basically any medical expense is subsided by every citizen in the country indirectly.

I believe this is a completely different way of looking at things than in the US. The average EU citizen doesn't really think that the monthly medical deduction from his salary is just for his use or it's his own insurance, it's only a contribution to the whole system.

This is how progressive taxation works. For some reason, US people happily pay for police, firemen, infrastructure or the military as a necessity of a functioning society but have serious problems considering healthcare in the same group.

County level vs national level

which in a lot of european countries, doesn't even exist as a differentiator.

Right but the biggest country in the EU isn't ~330 million people from about a half-dozen fairly distinct cultures. Remember that the US has cultural representation from many European countries and also quite a few non-European countries.

I'm not suggesting that Italy or Greece or Germany are actually homogeneous culturally but with smaller populations and significantly less immigration than the US I suspect that the variances are smaller and perhaps more surmountable.

Germany's population (83 million) is only about 1/4 of the US and as you go down the list the countries only get smaller.

Police and fire are paid for by local or state taxes, with some federal outlays via matching grant programs. Cities and states are free to start their own local and state tax funded programs. The only thing getting in the way is the enormous cost!

Because the US does provide for tax funded healthcare for the old (Medicare) and the pregnant/poor/disabled (Medicaid). The [cost of these programs](https://www.kff.org/medicare/issue-brief/the-facts-on-medica...) is greater than US military spending.

one could make the argument than the benefits of police, firemen, and military scale somewhat proportionately with wealth. people with meaningful assets have a lot to lose if the police stop protecting their property or the US navy can't guarantee relatively safe trade by sea. their house is probably worth more too. a homeless person probably gets hassled by police much more often than protected by them. socialized healthcare mostly benefits people who don't have and/or can't easily afford good insurance.

That's a very American way of thinking. I am totally fine that I contribute with a bigger part and it's used for people that would not be able to afford it.

I don’t know if you realize this, but when you write it this way it seems that you are implying an ‘American way of thinking’ is a morally inferior one.

Taxation in the US is significantly more progressive than in most (if not all) of Europe. In Europe, bulk of tax revenues come from high tax rates on middle class, while in the US, most of the tax revenue is paid by the wealthy. In concrete terms, Americans in top 1% of income distribution pay nearly 40% of all federal income tax, and top 10% pays 70% of all federal income tax. That’s significantly more progressive than all large European countries.

There's some kind of monopoly going on too: https://www.cbsnews.com/video/why-it-costs-so-much-more-to-d...

Before coming to any conclusions on this topic, I highly suggest reading this extremely in-depth analysis on cross-country healthcare spending.[1]

The simple answer is that Americans really do consume significantly more healthcare than Europeans. The most straightforward signature of this is the fact that a much higher proportion of Americans work in the healthcare industry than any other large country. The US also tends to consistently lead on the highest utilization of cutting-edge technology (such as ICDs, insulin infusion pumps, linear accelerators, and small bowel transplant) at any given time.

Cost per inpatient discharge is exactly in line with a regression of European countries against average household disposable income. (The US having nearly double the household disposable income as Western Europe.) Rather than being some signature of American dysfunction, globally we observe hospital bills rising super-linearly with income levels. This strongly suggests that hospital costs primarily rise because of higher intensity of care per encounter.

The strongest counterpoint to this is that despite America's high healthcare consumption, that health outcomes are significantly worse than Europe. In particular in terms of life expectancy. But healthcare economists have known for decades that medicine, on the margin, has virtually zero impact on health.[2] The US is an extremely unhealthy country, especially because of obesity. No level of healthcare would ever be able to counteract that.

But again this disjointed relation between medicine and health is not an American-specific phenomenon. The ratio of healthcare spending between Norway and Spain is about the same as between the US and Norway. Yet Spaniards enjoys significantly longer life expectancies than their Norwegian counterparts.

[1]https://randomcriticalanalysis.com/why-conventional-wisdom-o...

[2]https://www.cato-unbound.org/2007/09/10/robin-hanson/cut-med...

> The strongest counterpoint to this is that despite America's high healthcare consumption, that health outcomes are significantly worse than Europe. In particular in terms of life expectancy.

Just look at the life expectancy of France and Germany to disprove your theories.

The big difference between the American healthcare system and the one in these countries is that people don’t have to worry about the bills, which means healthcare providers have a much bigger incentive to learn what cost benefit analysis means.

> The big difference between the American healthcare system and the one in these countries is that people don’t have to worry about the bills, which means healthcare providers have a much bigger incentive to learn what cost benefit analysis means.

Can you go into a bit more detail about how exactly this incentive linkage works?

I'd really encourage you to read through the first link because it goes into very careful detail. But the point is there's nothing unusual about America's high spending given its very high income levels. In particular look at this chart from the source.[1]

Let's use France as a comparison point since you mentioned it. Household disposable income in the US is about 36% higher than France. That's about equivalent to the wealth gap between France and Slovenia. The US spends about 70% more per hospital stay than France, and very similarly that's almost the exact same spending gap between France and Slovenia.

The point being it's easy to ask "why does the US spend more than Western Europe?" But, analogously you should also ask "why does Western Europe spend more than Southern and Eastern Europe"? And the most clear answer is because wealthier countries tend to spend a higher percent of their income on healthcare.

[1] https://i0.wp.com/randomcriticalanalysis.com/wp-content/uplo...

> Household disposable income in the US is about 36% higher than France

I've seen the prices of procedures and drugs in France and in the United States (that is, before insurance, because no-one really worries about the price of healthcare in France given you get reimbursed more the more expensive your procedures are, which is how things are supposed to be), and it's definitely not 36% more expensive. Everything is at least 10 times more expensive.

Hey there. The comment you are replying to specifically addresses this.

I find reading comment threads containing comments that don’t seem to account for the literal assertions made in the previous comment tend to be difficult to follow and quickly degrade.

> The simple answer is that Americans really do consume significantly more healthcare than Europeans.

I do not believe this is correct.

From the OECD, average length of hospital stay across rich countries:

https://data.oecd.org/healthcare/length-of-hospital-stay.htm

We pay more but we generally consume less. EDIT: let me add this comparison of health prices across countries from the Health Care Cost Institute. See Table 1:

https://healthcostinstitute.org/hcci-research/international-...

Our prices are higher.

The US is an obese country, but you will find if you look that obesity rates are similar or worse in (e.g.) Mexico and some Gulf States (I think the UAE though I don't have a source for you).

We are not a wild outlier in terms of measured unhealthiness. Life expectancies here are lower though, despite vastly higher expenditure than other rich countries.

There are important failures on the supply side of the market:

From the OECD, we have fewer hospital beds per capita than most rich countries:

https://data.oecd.org/healtheqt/hospital-beds.htm

We have fewer doctors per capita than most countries:

https://data.oecd.org/healthres/doctors.htm

Failures of competition throughout the market (including hospital consolidation) keep prices high. We do basically zero evaluation of cost effectiveness.

Chargemaster prices (the non-negotiated price) are ridiculously high in the US. They’re so high that some hospitals will give uninsured patients a break of “half off” without even negotiating.

The reason for this is that chargemaster price is a fake dollar price resulting from a broken incentive structure and process. Here’s a setup:

A hospital is working out a negotiated rate for aggregate services with an insurance company. The insurance company wants to pay less, and they’re willing to put the hospital “in network” and bring their block of customers with them by doing it. But the negotiators on both sides aren’t going to sit and figure out the “right” price of every procedure. That would take forever (and there’s dinner at a Michelin starred restaurant to go to after this deal is done), so they agree that they will just pay some percentage of the chargemaster price, say, 50%.

Over time, the hospital administrators say “we need more money for this” and realize they have a lever. 95% of their customers are paying negotiated rates that are a percentage of the chargemaster price. The percentage is locked in stone, but the chargemaster rate? Yeah. They can change that.

The insurance company cries foul at their Michelin two-star dinner the next month, and the hospital agrees to lower the percentage a little in the next contract. Now the insurer is feeling flush, and the hospital is making about what they were doing before from that 95%. The remaining 5% who were uninsured are hanging upside down and getting shaken for loose change.

The cycle continues, and, eventually, the negotiated percentage drops to something comical, like 12%, but the chargemaster rates have soared. In the end, a pair of Advil “costs” $68 and uninsured patients have nosebleeds from being hung upside down for so long.

But there’s a new restaurant to try out, and someone else’s personal bankruptcy is a small price to pay for no-fuss managed care...

(Note: Marketing and administration accounts for more than a third of health care costs in the US, which is to say that health care bloat and weight due to a multi-player adversarial privatized system accounts for more than 5% of our GDP, so the chargemaster isn’t the only reason for sky high healthcare costs in America.)

I have a go-to piece on chargemasters here https://jaz.co.uk/2015/10/15/hospital-retail-pricing-for-dum...

(Worked on hospital pricing reports since 2001)

That’s a great piece thanks!

This is not that plausible as an analysis of the role of chargemasters.

I agree that the chargemaster prices are fake, but what you are proposing is:

Hospital: "Our insurance partners pay us a fraction x of Chargemaster charge X, so let's make C larger."

The insurer understands the game being played here, just like you do. It's not like the insurer doesn't also realize just like you do that the chargemaster price is fake.

The insurers are not going to say "Oh C got bigger this year? Well, let's pay more!"

More important are failures of competition in the marketplace, especially consolidation on the hospital side (most markets are now served by large hospital systems, so insurers cannot plausibly threaten to exclude hospitals from networks), the lack of exposure of consumers to most of the price, and the lack of incentives on the consumer side to search for cheaper prices (plus a general lack of any information about which facilities might be cheaper).

My understanding is the insurance companies are incented for C to increase as well - under the ACA insurance companies can only have a certain profit margin, so the only way to increase profit is to increase revenue and payouts.

From a personal conversation with an insurance company board member, I’ve been told this isn’t a factor as most aren’t running anywhere close to that line. The bigger factor in his eyes is healthcare providers building local monopolies. I don’t know how true that is, but I wanted to share.

Well he was just shoving the issues under the rug.

In fairness, he's not wrong, and neither is parent. Hospitals companies have local monopolies, which they can use to charge ridiculously high prices. On the other hand, insurance companies do get a kickback of sorts when the hospitals bump prices - the negotiators get compensation based on the dollar amount of savings they can bring from negotiation, so effectively, even if the hospital bumps prices high enough and renegotiates the chargemaster rates to a lower one, while still ensuring a profit for the negotiators, they'll go for it. Bloomberg did a nice write up of it a few years back, but it's now behind pay wall.

Yeah, that’s another good nuance. Ultimately many factors drive hyperinflationary healthcare costs. Everyone’s making money.

I think my takeaway from the whole conversation is that the insurance business can be counterintuitive to outsiders. Salvation may not be as simple as getting rid of them.

Another tidbit is that insurance companies don’t mind being the bad guys. I’m not sure if our focus on that industry blinds us to effective solutions for controlling costs.

I don't think eliminating private insurers is a panacea. I just think that the nature of incentives and negotiation between hospitals and insurers has resulted in plainly ridiculous chargemaster prices that harm uninsured and underinsured patients (including those who are "out of network").

Public disclosure and reputational price-indexing as well as regulation of emergency and regionally-monopolized non-elective care would help a lot, but backing the train up on decades of broken incentives and profit-optimized behavior is no small task.

I'm saying that the hospitals and insurers, while somewhat adversarial at times, are largely aligned in their incentives. Chargemaster prices can drift upwards while negotiated discount rates fall to compensate.

The hospital makes more margin off of people not covered by the insurer, the insurer is largely insulated from the change, and everybody comes away okay... except the uninsured patient who has no negotiating power.

I wonder how much truth there is in the theory that insurers are incentivized to let costs go way up and may be complicit in it. Basically the theory I’ve heard is that Obamacare limited by law the percentage margin that insurers can make as their piece of the pie. So then one of the only easy ways left for them to grow their profits in an absolute sense is to increase the amount of money flowing through the system.

The other factor is that hospitals have wised up over the years and started merging, which turns them into local monopolies and makes insurance companies price-takers.

I wonder if the reported prices are the aggregated total price for treatment? Or is it just a price of an individual procedure, excluding whatever else that normally goes into the treatment, like diagnostics, admin and nurse time, room/facilities expense etc?

Generally, every hospital reported price is different. Many of the prices reported are "all in" service packages, but several also wouldn't include these ancillary charges. Forthcoming price transparency legislation puts more pressure on hospitals/insurance cos to quote these "all-in" bundles. On the Turquoise site, we'll be representing all inclusive bundles with a checkmark + explanation that the provider has verified with us the rate is inclusive of all professional/ancillary charges.

I think this is a bit of an oversimplification; there are places where the out-of-pocket price ends up actually cheaper than the negotiated insurance price, which is mind-boggling to me.

A long time ago, when I was poor and underinsured, I had a medical situation that required imaging. The doctor’s office said they had the machines on prem, but they couldn’t give me any kind of price break. So he sent me to a specialist. Signing in to the specialist, they told me that the cash up front discount was 75%, and that even a hint of having to deal with insurance companies was going to mean a higher effective out of pocket.

Practically any US medical practice is going to have huge staffing overhead for the people who maintain the accurate billing records and wrangle with insurance companies.

I can directly compare with the French system: Doctor has a receptionist, you pay him cash right there on the spot, and he’s very limited in what he can do. E.g. he has to send you to the pharmacy to buy your shots, but he’ll administer them. When it’s all done, you fill out a crapload of forms, staple all the receipts to the stack, and your employer (via insurance) returns somewhere between 60-80% of it.

I have long maintained that moderate reimbursement for outpatient care would be a huge improvement for the US. At the same time, there’s a fairly large entrenched interest that wouldn’t like this at all.

One important piece of context here is that these rates are negotiated as part of a contract bundle where an insurer is bringing a pool of patients to the facility. Prices can vary widely procedure to procedure because they are associated with over or under representation of certain factors within that pool. For example, grossly simplified, I might have a particular service line, hip replacements (an ortho program). The insurer whose patient population is going to 'keep the lights on' in that service line is going to see a very different rate per service than a different insurer who rarely has patients that need it. Nothing about these prices shown are really reflective of the costs of doing the procedure such as pricing in a retail store.

I do think this transparency initiative will result in more consistent costs but not necessarily net lower costs.

Comparisons to other countries that are smaller than the united states are somewhat apples to oranges. There are a lot of factors that are glossed over when someone says "costs are 5x higher in the US than my country" including real estate, energy subsidy, and so on. Its a deep well.

Just came here to remind everyone that free at the point of use healthcare is great.

I tried to total the cost of the care my son received when he was born, had we been American. I stopped counting at $1million.

Being in the UK, I even got a few meals at the hospital canteen thrown in. Not to mention the time in nICU etc. It is horrifying that people have to compare prices and haggle for care anywhere on earth.

Fun fact - I'm a cofounder of this and a US citizen, but I live in London. I agree completely with this. I spend my days working on US healthcare data and seeing how crazy it is while I use the NHS for my actual care.

But the US system is tricky because while it is an huge mishmash of layers of middlemen and clearing houses taking a slice of the pie, those layers also employ a huge number of Americans across the country. It would be extraordinarily difficult (both logistically and politically) to rip all that out in one fell swoop. I feel like the only possible way to bring in socialized medicine in the US would be a gradual expansion of opt-in 'Medicare for All' or something along those lines.

It doesn't seem like there's a way to do it without aggressive opposition, really. Divide and rule (taking out one rentier middleman at a time) will take decades I'd imagine.

So yeah, expand and improve existing programs until they're universal and comprehensive like the NHS. Sane approach.

Even I am surprised:

Appendectomy: MSDRG 343: at Kaiser in Santa Clara: $56,000

Appendectomy: MSDRG 343: at Holston Valley Medical Center, TN: $4,700

Our healthcare system is even more broken than I ever imagined.

Too bad it is an emergency condition, otherwise people could just fly to TN for the same procedure...

I used to think that, but my wife had one last year and she only got her surgery almost 2 months after the diagnosis. She was on antibiotic the whole time to reduce and control the infection. Apparently it's the new way to deal with it, since it makes the surgery much easier to perform, instead of when the patient is in pain.

Anecdote aside, your point stands. Shopping, across state lines for surgery is ridiculous.

For a contrast [1] from the other side of the pond, you could get by on about $3k USD (most British people have no idea about this! [2]):

> RESULTS

> Fifty laparoscopic appendicectomies were performed. Median operative time was 60 min. The median total operative cost of laparoscopic appendicectomy was £906. Median equipment cost for laparoscopically completed cases was £254. Median total in-patient cost was £1617 (range, £880–£3360). This compared with a mean re-imbursement of £1981 representing a [hospital] cost benefit of £233 per case (P = 0.0009).

> CONCLUSIONS

> Despite a liberal use of disposable equipment, laparoscopic appendicectomy can still be performed within the confines of the national tariffs. There is a considerable variation in the cost of this procedure, and it may be possible to reduce costs by more stringent use of disposable equipment and standardising recovery protocols.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966171/ [2] https://www.theguardian.com/society/ng-interactive/2016/feb/...

Yeah that's a generally interesting one because Kaiser's pricing is inflated assuming that all their patient's also have Kaiser insurance. But appendectomies do range quite a bit.

What does pricing at Kaiser even mean? When I last looked at them, every plan had a $0 deductible and even surgery just had a single copay. Is that the price for someone out of network who goes there in an emergency?

What the ..... My wife paid non evasive extraction of appendix 600 euros in a private hospital (and was an emergency) in East EU and is considered luxury by some. It's free in public hospitals.

You guys are swimming in cash.

Do not draw conclusions from this specific case because Kaiser in particular is very, very different.

You may be able to find similarly insane examples at other hospitals, but Kaiser is vertically integrated: generally Kaiser doctors send Kaiser-insured patients to Kaiser hospitals.

I am not sure how they reach their measure of a "price" here but it is entirely possible it's unusual and or different.

Again you can probably find something similar at non-Kaiser hospitals (Just for fun... check the Sutter system in NorCal - it's extremely expensive), but Kaiser is not the reason you should think this is insane.

This seems to be the GoodRx of medical procedures. This is tremendously helpful.

How do you plan to keep the data current?

Also, in the US, is a patient realistically able to say, “Hospital X is able to get my compound fracture surgery done for 65% less. Match it or I walk”, especially when insurances have negotiated rates.

Or is this only useful for people with no insurance?

Hey man! This is a great comment. I work with Turquoise. We're actually building some stuff where patients can collectively bargain outside their insurance. But for now, it's most useful to people with insurance that see that one hospital down the road has a lower rate for their given insurance. (EG, the blue cross rate is better the next town over). We're going to make it easier to filter for insurance shortly.

Also, very useful for cash pay.

This is an amazing product and I congratulate you on your launch! Like the parent, I'm also really curious how you plan to update the data and also wanted to ask how you normalized the data.

I ask because this space has always been interesting for me. Funny enough, I helped build almost the exact same thing at a hackathon (https://devpost.com/software/liform), but the project didn't pan out after that due to our team's lack of medical knowledge. So I'd love to learn from your experience processing this data into a usable form.

I just read an article about quiet / dream jobs (park ranger etc.) In it, every single person has a side gig(s) or is otherwise making decisions on their careers based on medical coverage. Every one of them! One of the people says most people leave when they turn 26 because they can't stay on their parents' health insurance. What?!

  > And like other dream jobs I learned about, it’s not enough to survive on: During 
  > off-seasons, Krumbholz also works as a substitute teacher and an aquarium dolphin 
  > tank cleaner; since being on university health insurance would mean she’d constantly
  > lose it during the off-season, Krumbholz decided to stay on the state exchange
  > instead.

The idea that health care is tied to your employer, and your employment status, is so unacceptably broken. I've never heard of anything so broken in terms of the obvious social and economic harm a bad policy is creating. Having the freedom from health care costs is more freedom for more people than the "freedom" to not pay health insurance or taxes to cover it.

That sounds extreme. Without taking sides, I suggest another possibility is that the author may have a bias, agenda, or angle to the story.

// Having the freedom from health care costs is more freedom for more people than the "freedom" to not pay health insurance or taxes to cover it.

This is not how freedom works. Your argument is akin to saying "freedom from hearing uncomfortable opinions" benefits more people than "freedom of expression" does.

On the broader level, I got to experience healthcare in the US both as a broke-ass immigrant child and as a working adult. It ranged from good to amazing in terms of availability of appointments, treatments, quality and comfort. Night and day beyond what I experienced in the USSR as a kid. So while people are shitting on the system we have, many people find it excellent and amazing and we like the freedom to continue enjoying it.

Would the general public of other developed nations be happier if their healthcare systems were more like the US's?

Haha nope, ya’ll be crazy

I've lived in the US, and now live in Canada.

Despite right-wing propaganda that we're all flocking to the states for care (never met a single person who has even considered that), or that we're all dying on years long wait lists (there is an element of truth to that, but it's a triage system. So cancer patients get priority for surgery before the skier who blew his ACL).

I still have yet to meet a single person who doesn't think the US system is batshit crazy.

Canadians recognize that their system has problems, and can be improved (which is true of ANY complex system). But they also don't think that the US system is functional or desirable.

I know that the nearest border crossing to me regularly has ambulances waiting for people that preferred to travel sick or injured than seek healthcare in the US. In other words, people literally flee the country to avoid being treated in the US.

Is curious, but I had heard exactly the same advice before. In case of a minor accident or health issue as tourist in US, try to leave the country ASAP unless you have a solid travel insurance. In any case you will be not allowed to fly with a fracture (if I'm not wrong).

I doubt it.

In any case we have public and private hospitals. Paying an insurance for assuring a "premium" service with better rooms or faster treatments (closer to the US system) is also an option.

My experience as a child was great. As a working adult I spend hours fighting with insurance, hospitals, and doctors to get my bills properly covered. It feels like a bunch of wolves arguing over whose gonna eat the sheep (me). For this privilege I get to pay insurance a minor fee of 3k/month for my family of 5.

There definitely had been a few snags with insurance that we had to work through - not claiming it's perfect.

However I recall the night my son was born - the facilities, staff and resources of the hospital were unmatched - the mother and baby would not have the same experience anywhere else in the world.

My wife works in the ER - they constantly use procedures and deploy resources in ways that would be considered impractical elsewhere in the world.

For example: an 65+ year-old patient comes in with a specific complaint. It could be cause A or the more rare but serious cause B. It takes imaging to determine whether it's A or B. Elsewhere in the world, they just assume it's A as the patient is "old" because it's financially impractical to test for B. My wife on the other had has no constraints from ordering the imaging test even though 9/10 times it's "wasted" as it just confirms A. But the other 10% of the time, it saves the life.

We make a different tradeoff in the US, some of us prefer this trade off.

> For example: an 65+ year-old patient comes in with a specific complaint. It could be cause A or the more rare but serious cause B. It takes imaging to determine whether it's A or B. Elsewhere in the world, they just assume it's A as the patient is "old" because it's financially impractical to test for B. My wife on the other had has no constraints from ordering the imaging test even though 9/10 times it's not needed. But the other 10% of the time, it saves the life.

This just plain isn't true in general. I grew up in the US with probably the best insurance of anyone I've ever known. I've also lived in Sweden with the state-run insurance (without any private addition). I've had great care in the US. I've had great care in Sweden. In fact, my care in Sweden has honestly probably been better in my cases including where I had overuse injury to my knee due to sports where they really could just say "well quit running so much and let your body rest and leave the healthcare system to those not actively inducing their own injury", but they did not. Fast MRIs, fast diagnosis, fast help, fast everything. I understand this is entirely anecdotal, but the fact is there are many much cheaper systems out there run by governments that actually function _better_ than the US system even for those in the US with good insurance.

> However I recall the night my son was born - the facilities, staff and resources of the hospital were unmatched - the mother and baby would not have the same experience anywhere else in the world.

We had a wonderful experience with the birth of our daughter, but I have no idea how I could claim it was better than anywhere in the world. I'm asking because you seem to be making a low-hyperbole claim here: what is your basis for saying that? Particularly, when the US has some of the worst metrics for infant mortality, birth weights, and mother mortality rates in the developed world.

> My wife works in the ER - they constantly use procedures and deploy resources in ways that would be considered impractical elsewhere in the world.

Does this actually lead to better health outcomes? The US ranks low in the developed world in many health-related areas. Some of them are at least in part due to cultural issues and it is completely fair to attribute to our healthcare system. But some of them like our rates of medical and lab errors clearly are. I'm genuinely looking for data to support the idea that the tradeoff you mentioned actually exists.

// but I have no idea how I could claim it was better than anywhere in the world. I'm asking because you seem to be making a low-hyperbole claim here: what is your basis for saying that?

Conversations with friends and family abroad.

// Particularly, when the US has some of the worst metrics for infant mortality, birth weights, and mother mortality rates in the developed world.

Not an expert but I understand there's a ton of measurement variability. Something like:

Baby born 3 months premature and dies shortly after. Many countries just consider that still birth and it doesn't count towards infant mortality. In the US we actually fight to save these kids so if they die, they count towards infant mortality. Perhaps weight at birth works the same way?

All countries do their best, and Sweden seems to be the most successful country at the moment [0]. Neonatal mortality rate in Sweden was 1.38 per thousand in 2019, compared to 1.4 in Norwy, 2.77 in the UK and 3.7 in the US [1]. But you are right that the rate of premature births is higher in the US than most European countries (10-15% in the Us compared to <10% in Europe) [2], and so is the rate of very preterm births (14.1 per thousand in the US compared to 8.3 in Norway, 7.7 in Sweden and 6.7 in Finland) [3]. It is likely that the rate of premature births is also a sign of the quality of maternal care.

The rate of still birth in 2009 in the US was 2.95/1000 compared to 2.74 in Sweden and 2.2 in Norwy [4]

That the statistics of neonatal deaths are manipulated is also a bold claim, it deserves some references?

[0] https://news.ki.se/sweden-leads-the-world-in-saving-extremel...

[1] https://www.who.int/data/gho/data/indicators/indicator-detai...

[2] https://www.reddbarna.no/born-too-soon-the-global-action-rep...

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346062/

[4] http://chartsbin.com/view/1445

Edit: spelling

There is a huge Caviat in your scenario. A lot of people won't come in because they can't afford it, or they won't get the test because they can't afford it. Your wife can order the imaging test, but she doesn't have to deal with the debt, and/or months of arguing on the phone with administrators that her patient sees.

I live in Canada where I am enrolled in the provincial health plan. If a doctor recommends a test or treatment I get it. Cost isn't a consideration. My age isn't a consideration. Please don't spread lies about how universal healthcare works. Unlike insurance in the US, if the doctor orders it, it is covered by the healthcare system here.

Truth: I may have to wait based on a triage system.

If the doctor doesn't recommend a test as necessary or I don't want to wait for my place in line, I can go to a medical clinic that offers these tests privately and pay/have my employer provided secondary coverage pay.

In that way it turns out that we don't have to make the tradeoff.

I've had the best insurance I could buy in the US, and now I have the standard health care that every person in my Canadian province gets. My experience, which is backed up by studies, is that I am healthier, and the population in general is healthier under the Canadian system.

YMMV (as I'm sure the below comments will show you) on the efficacy of the US healthcare system. My experience ranged from 1/10 (like denying emergency care until I fought for it) to 10/10 (same-day treatment after diagnosis). Even from the supply side, I have little power on how to help even my own patients navigate the system unless it's an urgent/emergent need. It is important to hear the system is working well for some; we should focus on improving it for more people.

That may be true but the USSR is a collapsed state, we should be comparing wealthy countries.

According to this the US is mostly in the high top 10 for outcomes in cancer and cardiovascular disease treatment outcomes:

https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...

But the US spends more than double the OECD average per capita to achieve those marginal gains:

https://upload.wikimedia.org/wikipedia/commons/thumb/0/0b/OE...

There's an argument to be made that the cost overruns are paying for better outcomes, or maybe the outcomes have some sample bias due to Americans being less healthy, or sicker people are seeking treatment in the US.

But on the other hand, the gains are so marginal that those costs might also be due to significant corruption and regulatory capture.

I didn't make this clear - I agree with you about the USSR, but the point I meant to make is that on metrics like cost and availability of care, it would look "better" than the US.

No one who is legit just compares cost and availability they are going to also include the health levels of the nation, time to actually getting an appointment, time to get a surgery for a condition, etc. You can't just pick out two variables and say "see I'm right!" . There are a ton of European health markets that are superior to the US market when comparing multiple variables. We need to copy them or do something very similar rather than being stubborn assholes and think everything has to be home grown.

You're being single minded here. You should compare it to what is available in Europe, Cuba, Canada, etc not what's going on in Russia. We want everyone to have good health care, not just people in silicon valley and the tech industry who by and large to get good insurance.

If folks had to butcher their own cow, there'd be more vegetarians. And if folks had to shop and pay for their own health care plans on exchanges like the self-employed do, we'd have universal health care.

Employer based health insurance should be abolished. There should be one risk pool either nation or state wide and within that everybody can get insurance for the same price. It would reduce a lot of administrative effort in companies (why does my employer have to worry about my health insurance but not my car insurance?) and allow people to change jobs without worrying about health care. Religious employers also couldn't control things like birth control because health insurance would be none of their business.

I like this idea, especially nation wide. I think the US should set one up along side private policies though as a stepping stone so people can see/envy it. You will never ever get rid of private insurance in one fell swoop it will take steps.

it should be, and it needs to be if we ever want to fix this problem, but it'll be political suicide for anyone that even says this out loud. corporations would be all for it to.

(majority of) people with jobs have no idea how bad/expensive healthcare really is. they have excellent insurance coverage and they pay very little for it. if we make them responsible for buying their own it'll be impossibly expensive. but this is exactly what they need to realize so that we can have the political movement to overhaul the entire system

"they pay very little for it."

That belief is the problem. You pay for it with reduced salary. Problem is that this fact is being hidden. Then you also have your employer choose insurance plans for you but their selection criteria are most likely for their own benefit.

My first question to a potential new employer has become "what are your health insurance benefits and how much do you cover?" rather than "what's the salary range you're hiring for?" (although this still comes second). If it's anything less than 80% employer-paid coverage or they don't offer traditional PPO plans, it's an automatic withdrawal of my application.

I've recently found I now need to add another filter to this: "WHO is your insurance through?" because apparently even 90% employer paid health insurance through UnitedHealthcare still sucks compared to inferior coverage through BlueCross or Aetna. I had to switch primary care doctors for everyone in my family (me, wife, kids all had different docs) because none of them were in network with United. Confused by this, I called around. I found out doctors offices loathe dealing with UHC due to UHC's reluctance to pay or the generally obnoxious claims process. Their "in-network" providers is contained to a much smaller list of providers that put up with their bullshit. I'm seriously considering leaving my current employer (which I'm very happy with) for this reason alone.

Lack of reliable (or any) health insurance is the #1 reason I don't take contract jobs even though they're more attractive to me.

A number of people, including me, have been building similar things, see http://price.hospital

The problem seems to be figuring out a revenue model, and translating all the medical terms in to human.

Same, I've been mapping out CA average prices at http://hospitalprices-env.eba-r2yhwdcw.us-west-1.elasticbean...

Comparing just the price of a hip replacement is difficult, because there are so many other services that will bundled in with a hip replacement (anesthesia etc) that may not be represented in the service price alone.

The "average cost by diagnosis code a patient comes in with" transparency requirement is an attempt at solving that, but doesn't differentiate between insurance plans.

Also, I love OpenStreetMap, thanks for your work on that!

Are you scraping this or just visiting each site manually and getting the machine readable data? Cool stuff!!

California collected all of their hospitals' data at https://oshpd.ca.gov/data-and-reports/cost-transparency/hosp...

The average prices for common procedures is on the 1045 sheet

I have my gripes with California but I love that they did this

Woah, I'm a CA resident and also surprised and happy. Are you seeing a lot of non-compliance?

Compliance seems pretty good. The ones I haven't imported are because they're using an unusual format. Compliance on the new 2021 rule about payer-negotiated charges seems very spotty though.

Would be fun to chat - my email is in the profile, tried finding yours...

For us, the revenue model isn't this site itself. It's other work we do in the industry - this just helps us get notice and leads to the other things we can build on top of this data in combination with other data. I'd be happy to chat more about this if you were ever interested.

Side note - I'm a long, long time OSM fan and contributor. Thanks!

We're running a $10,000 bounty to assemble this information into a queryable database:

https://www.dolthub.com/repositories/dolthub/hospital-price-...

You get paid based on the percentage of rows you contribute to the dataset. So if you fill in 20% of the rows, you get $2,000.

More details here:

https://dolthub.awsdev.ld-corp.com/blog/2021-01-14-hopsital-...

This is amazing! Will the data be public after it's assembled?

Yes. It's public now, just incomplete.

Congratulations on the launch!

Turquoise Health could be solving this need gap - 'How much will I be charged for my treatment'[1] posted on my problem validation platform.

You're welcomed to explain how Turquoise Health helps solve their problem in that thread.

[1]https://needgap.com/problems/122-how-much-will-i-be-charged-... (Disclaimer: It's a problem validation platform I created).

Here’s another consideration: care quality is very disparate across the country in the US. And what’s even more frustrating is that cost is not correlated to quality. While I am a bit more critical because I’ve seen “how the sausage is made” first hand for years, this also makes it that much harder to implement universal health care in the US. Don’t think someone living in rural Wyoming should pay the same HC tax/premium as someone living right across the street from MGH.

Definitely true - quality and price are only very loosely related. Right now we have care quality information on the hospital "information" page, but most people aren't finding it in the current design and we are going to re-work it so it's more visible when browsing prices.

How accurate is this? Some of the threads point out extremes between different hospitals, is that because X hospital does more stuff then Y, and Y charges you the same as X it's just a bunch of hidden/extra stuff that isn't billed as "MSDRG 343"? Or is it because the hospital like any business can charge you what ever you want and may charge more or less depending on the neighbourhood, rent, etc?

I think part of it is that there is a huge difference in cost between some facilities. But another part of it is that a lot of hospitals don't really know what they charge. They had to scramble and hire consultants to come up with these numbers to meet the deadline and the numbers will probably get more accurate and vary less over time as hospitals get better used to working with prices out in the public.

Cardiac valve procedure at Kaiser Foundation Hospital - Redwood City Medical Center - $458,254.00 cash price. Oh my.

I get it that it's an expensive procedure, but OH MY.

Kaiser might be a weird outlier. IT is a very different kind of organization (vertically integrated - physicians/insurers/hospitals).

It might be that the price is that insane elsewhere, but Kaiser may not be the best way to judge.

Looking at some of the prices, I can't help but think how great an incentive it is to be healthy in the US. "Health is wealth" if it applies anywhere it is in the US.

I have taken extra measures to ensure that myself and my family are healthy in the last year and with a tax-free HSA account that is invested into ETFs, I am literally printing dollars just by following basic principles of being healthy.

Health privilege becomes a thing when access to healthcare becomes a barrier. I know the word ”privilege” is quite radioactive.

I was sick often as a kid and after finding a diagnosis I’ve been performing well among my age peers. Thank you Finnish healthcare. Couldn’t imagine how much it sets you back cognitively to have health issues as well as financial issues burdening your mind 24/7. Completely avoidable pain and suffering purely for profit.

Agreed. I was just looking at the positive aspect of it.

Looks interesting. How is this different than test claim submissions available from Eligible, Waystar, PokitDoc, etc?

And are you licensing out cpt codes from the ama? IMHO the AMA and their copyright of CPT codes is the biggest setback to progressive change, transparency, and adaptive change in tech... Payers and well funded companies can afford licensing, otherwise they will strangle you with lock down...

I had this exact idea ~6 months ago but didn't know where to begin. I'm sincerely glad someone else built it. We're in such desperate need of justice when it comes to U.S. healthcare and this is a really good first step in holding the system just a little bit more accountable.

Great solution. I hope this will make asking about costs at the hospital more normal!

I once went to a doctor for vaccinations before traveling. The nurse said "You need X, I recommend Y, and the CDC recommends Z." I responded "great, let's get X right now. Not sure about Y or Z - how much do they cost?"

The question just didn't compute. No matter how I phrased it ("just want to price compare" ... "there's a bunch of travel clinics and I'm trying to get this cheaply" etc), I couldn't make myself understood.

The NP ended up coming in to give me their "anti-vax" spiel. I had walked in to a hospital wanting a vaccine, and asking about costs was so foreign to them that they thought the only reason I could hesitate to get a vaccine was anti-vax sentiment.

All this to say - this tool is very much needed, and has the potential to do a lot of good!

The branding (design, typography) looks very similar to OneMedical.

Is there a Walmart for medical procedures? A jiffy-lube?

Come to Brazil. The best Brazilian hospital (Albert Einstein Hospital in Sao Paulo) charges 1.7k USD for a C section (my son was born recently there), while the lowest I've found in that site is 2.6K USD (don't know about the quality) and median seems to be 8K USD. I bet the other procedures have similar price differences.

You can pay for the trip, get the best care (it is a really good, international level, hospital) and still have some loney left.

And what about an MRI? This website lists rates around 2k USD, while in Brazil you can get one (in high-end modern hospitals in São Paulo) for around R$ 600 (== $120).

MRI in Mexico cost ~$200 USD ( https://www.chopo.com.mx/zapopan/estudios/resonancia-magneti... ) and is way closer than Brazil.

There are laboratories even at walking distance of the USA haha ( https://www.google.com/search?tbs=lf:1,lf_ui:4&tbm=lcl&q=lab... )

Might be interesting to check how much "Medical Tourism" happens between US and other countries. This might be an interesting industry to get into. If I remember well there was a health insurance company that was promoting Medical Tourism for their clients

That was my thought. If I had the money, I would setup one or two clinics in Nuevo Laredo, Reynosa, Juarez or Tijuana, fill it with really good, English speaking health professionals and promote the heck out of it in the USA for medical tourism.

Closest thing is Surgery Center of Oklahoma, which does not deal with insurance and has an easily accessible public price list on the web site.

https://surgerycenterok.com/about/

This Econtalk interview with the founder is very enlightening:

https://www.econtalk.org/keith-smith-on-free-market-health-c...

You mean Walmart Health?

https://one.walmart.com/content/usone/en_us/company/walmart-...

:-)

Yes, CVS MinuteClinic.

Very cool! We've been working an app that is looking for this exact type of data. Do you have an API or plans for making an API for this?

We do have plans for an api, but we are currently working out the model for it - feel free to get in touch via the site and let us know you are interested and what you might want to do with it.

Thank you. Just did.

Oh wow, so a "Tonsil Removal (Patient Under 12)" procedure has a huge price-range:

$298.00

$7,830.76

$7,299.85

$10,243.23

$13,964.19

---

How are these even comparable?

It's probably bad data. 7k vs 13k is reasonable, but nobody is removing tonsils for $300.

$300 seems low to me as well, but the order of magnitude spread isn't suprising at all. About 5 years ago I went into the ER in NYC due to extreme dehydration. They gave me some saline and sent me home a few hours later. Later I got a bill for $250 which was above my ER $150 copay so I called them up and it turned out they didn't realize I had insurance. A month later I got a "fixed" bill for $3000 to my insurance of which $150 was my responsibility.

My example of a magical 12x increase given single exact same procedure coded identically, means I find a price increase of ~43x from $300 to $13,000 between different hospitals quite believable.

It would be nice if I could set my insurance plan once, and then see the cash and insured prices in the search results.

This is in the works! We hope to implement this as soon as we've cross-referenced all the plans across providers.

And of course the FTC doesn’t care about the blatant anticompetitive behavior by hospitals.

Where do you get that from?

The FTC has challenged a lot of hospital mergers. They are not always successful, but they do challenge them.

Source: healthcare/competition economist.

Can someone explain why US medical costs are so absurd? Why is it the way it is?

You all should check out https://www.sidecarhealth.com their insurance pays 100% of the cost in cash to the care provider, thereby brining the cost of care 40% - 60% less.

This sort of thing must make some cheaper alternatives appear.

FYI, you have a typo on the home page.

> isn’t an MRI and MRI?

Hope this was available for India

This was a big accomplishment of the Trump admin. Regardless of what your other opinions of his administration are, healthcare pricing transparency in the US is a very important step forward to improving the healthcare situation there.

Source (one of many): https://www.reuters.com/article/us-usa-trump-drugs/white-hou...

It’s too bad that all the other insane things he did will overshadow literally anything of value that he accomplished.

Could you enlighten me and name some of those things? Not things he said, but things he did according to you.

These are all well documented:

https://www.indy100.com/news/donald-trump-bad-things-list-b1...

There are 55 things on the list. There’s a mixture of things he said and things he did. As president, his words have real consequences, so drawing the line at “things he said” is strange.

Are you serious about bringing that article/site to the table as a source to try and make your point? Or is this sarcasm?

Don't feed the troll.

His attacks on the immigration and asylum systems were particularly insane and cruel. A just future will forever associate the man with this dark period of Family Separation and caged children.

President Obama's DOJ broke the asylum system by allowing local non-state crime or poverty to be grounds for claiming asylum. This change triggered the family/children caravans and general flooding of the border with women and children.

The 2017 tax reform bill [1] "seeks to address some widely acknowledged issues with corporate taxation, and takes some steps toward broadening the tax base, in part by reducing the incentive to itemize deductions." It was the first substantive piece of tax reform since 1986, and while there are many things to criticize, it at least started to align US corporate tax rates with those in other developed countries.

One of the significant changes that the tax reform brings is an increase in the cost of capital raised in the form of debt. That is a good thing. The deductibility of interest on corporate debt creates an enormous distortion that causes firms to favour leverage, which leads to greater instability in the economy. Should interest be tax deductible? Well, whether or not you think it should be, it is. And so reducing the corporate tax rate makes that deduction less valuable than it was before.

The tax reform is hugely regressive in reducing the top marginal tax rates for high income earners. That is a giant negative IMHO, because wealth and income inequality are a huge problem in American society. So, personally, I believe the only good from the tax reform is on the corporate taxation side by, effectively, making things a little more efficient than they were before.

Other things that I think were a positive:

1. Rejecting Chinese firms' from the 5G network build-out. His diplomacy and trade policy were really random, but this was one move that worked out well.

2. Operation Warp Speed. While Hillary Clinton likely would have done a FAR, FAR better job of handling the pandemic overall, credit is due to Trump for getting behind the advanced purchase of billions of dollars worth of vaccines before they were even approved.

3. Greatly increasing the standard tax deduction for low income earners. "For income earned in 2020, single people pay no income tax on their first $12,400, heads of household on their first $18,650, and married couples on their first $24,800." [2]

Again, it's too bad that all the insane stuff he did and all the things he neglected will overshadow his accomplishments. History will likely judge Trump harshly, which I think is richly deserved.

[1] https://pubs.aeaweb.org/doi/pdf/10.1257/jep.32.4.73

[2] https://www.theatlantic.com/ideas/archive/2020/12/the-things...

Agreed. This is only a small first step towards some level of sanity but let’s hope that the Biden administration keeps going down that path.

How is it possible that this was not required before? I am so glad that we had Trump, even if it was just for 4 years.

Came here to post the same. My guess is he will go down as the worst president in US history, but even a terrible administration can have a few noteworthy accomplishments. This and the airline reforms (1) will probably be remembered as the best things that came out of the Trump administration.

1: https://www.inc.com/bill-murphy-jr/president-trump-just-sign...

Seems a sensible bill - amazing that some of them were not already the case. Eg. mininum rest times for cabin crew.

However, what on earth has this got to do with aviation?!

> authorizes $1.68 billion for relief for Hurricane Florence, which hit the Carolinas last month;

That's how those bills work. It was either the most expedient way to get it in a bill or the Carolina congress people were needed to pass it.

Oh, I assumed the greatest accomplishment of the Trump Administration was the peaceful transition of power to the new administration? This does seem like a good thing though.

How do we disrupt the fucking debacle that is US healthcare?

Would it be possible to create a subscription-based health network that was vertically integrated and provided just basic outpatient needs? Charge $9/mo or something ridiculously low and encourage everyone to check their health often and maintain healthy lifestyles?

Use automation to reduce costs. Then gradually increase the scope of care.

That won't help with surgery, cancer, childbirth, etc. right away, but it might create a gravitational shift that puts swaths of expensive general practitioners out of business, creating excess supply and lowering the range of what insurance covers. That might greatly reduce costs.

We have to eat away at this bloated, inaccessible system somehow.

IMHO You need to make it legal to open and run a hospital (hospitals are basically local state-granted monopolies like cable companies). You make it legal to offer differential pricing. You decouple healthcare from employment. You allow employers to offer more than one insurer.

Most of what we need to do is just remove the monopoly rules.

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