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Comment by helloguillecl | Hacker News Reader

This is absurd. Even in a country with liberal economics and "free choice" health system (however with universal care, and state regulation), the same stitches in a world-class private clinic in Santiago, Chile would cost 400 USD, before insurance. The clinics there are not the ones Americans imagine from a middle-income country, most of them have better infrastructure and doctors than the ones I know in Europe. And I don't even need to start talking about health services in Europe, where I live.

This is the kind of things that show how inviable is a market-led economy without proper regulation. Let the powerful profit from the weak and you'll see this kind of thing every time.

If you compare life expectancy in Chile and some other Latin-American countries with universal care[1], they are higher than in the US, despite being a more unequal and/or poorer.

[1] https://ourworldindata.org/grapher/life-expectancy?tab=chart...

Edit: Many commenters miss the point. The US leads the way in too many areas and at least I expect them to be an example of the benefits of free market economy. Some have mentioned that regulation is indeed the problem. I would say, that we need the right regulation so the right incentives are put in place, in benefit of the market and competition. So at best it would be better not to have the industry dictate the regulation.

View on HN

The plastic surgery and vision correction industries work pretty well in the US. You see price competition and patients have the ability to shop around and make choices that are important to them (references from other patients, doctor personality, etc).

Now contrast that with going to a hospital for a procedure where you have time to shop around. Can you get a price? No. Can you easily get appointments with doctors to get their opinions on your case? Maybe. Can you get other patient references? Unlikely (but maybe).

What’s the difference? One insurance covers (thus the patients is cut out of price conversations) and one insurance doesn’t cover (this patient is the end payer). The big problem is more and more costs are being shifted to patients as deductibles and co-insurance, but hospitals treat it like it was 1990 and the patient pays some token amount so “who cares”?

And sure, an emergency doesn’t leave you much time to shop around, but something like 80% of healthcare procedures aren’t emergent.

>What’s the difference?

The difference is that one is completely optional and you can spend as much time as you want comparing options, while the other you're forced to do on a whim at whatever place is closest. You can't shop around when you're bleeding out, as in the article. And such emergency health care constitutes most of these surprise bill situations.

You’re missing two key element of the process - the willingness to exploit, and the lack of alternatives.

Centralized hospital and clinics in certain locations. Don't allow building healthcare based on maximized spread. When there are multiple alternatives next to each other, it generates not just competition for customers (patients) but also doctors/nurses employments. Also build fully government subsidized hospitals in each of this location to force the private pricing not escalating. Then every hospital admins will need to undergo 6mths IRS audit. This force the job extremely undesirable and reduce the demand for it.

Basically what I said in my last paragraph?!?

Really any healthcare procedure that is not typically covered by insurance has seen costs go down over time. Things like lasik eye surgery, or orthodontics are great examples in addition to the ones you've already mention. The service and technology gets better while the price continues to go down.

> Really any healthcare procedure that is not typically covered by insurance has seen costs go down over time.

Health "insurance" companies are incentivized to raise the cost of care. Why? Their profits are capped to a percentage of the cost of care. The only way for them to make more money is to have more revenue -- which they do by increasing the cost of care!

Bakeries are also incentivized to raise the cost of bread, in spite they have no official cape of the profit (unless you consider 100%?).

The difference is that if a bakery tries to charge you a ridiculous price, you can politely decline tu buy, or buy and promise never to return.

Let say you go and pick up a loaf of bread from the store. You don't pay, however. Instead, you have the bakery send a bill to your "buyer." Your buyer then negotiates the price. One thing about your buyer: the more revenue that flows through them, the more money they get to make. The bakery tells the buyer that the cost for the loaf of bread is $500. However, the buyer wants to keep you happy, so they reject the price, and come back with a lower price: $350. The bakery rejects the $350 price, and eventually, the two parties agree that the price should be $400. (Note, that other bakeries, where you buy directly, charge $4 for a loaf of bread.)

The buyer gets to say they negotiated. The baker doesn't have to look you in the eye when they gouge you.

It gets a little more complicated,though. Instead of just paying $400 for the loaf of bread, the buyer bundles the cost of all the purchases together, and then charges a monthly fee, based on the previous year's overall revenue. They then tack on 20%. So, it turns out, with that extra 20% you're actually paying almost $500 for the loaf of bread anyways.

Is it a scam?

Yes, it's a scam.

The difference is that the customer pays 100% of the entire price. The industry doesn’t have a plan where you pay $0.10 for an eggs benedict brunch, or 10% a year after spending $100, and then get to charge your employer or your fellow citizens massive sums.

And someone can start a competing bakery across the street that doesn't over charge. You can't do that with healthcare.

> The service and technology gets better while the price continues to go down.

What did you think the farmer who was charged $6,589.77 for 6 stitches might have to say about that proposition?

GP is talking about:

> any healthcare procedure that is not typically covered by insurance

Which I (not American) assume stitches in the emergency room are.

Yeah that doesn’t preclude the farmer from having an opinion about the proposition.

Why do you think this discrepancy occurs?

Sure the farmer can have an opinion, but I’m not sure how

> who was charged $6,589.77 for 6 stitches

is relevant when OP was talking about procedures NOT covered by insurance.

"I wish stitches were done on a fee for service model like shooting lasers into people's eyes is."

That was still a FFS model. The difference is whether the procedure is typically covered by insurance.

I don't see how it's fee for service if nobody can tell you what it's going to cost upfront.

The uncertainty comes from not knowing exactly what services will be performed, who will be performing them, and how much the insurance company will cover (which has a ton of variables, many of which aren't known until everything is settled).

In my opinion, getting away from the fee for service model is one of the routes we ought to be taking to address healthcare spending in the US (if you're charging per service, you're incentivized to perform as many services as possible in a given encounter).

In other professions if you make a bid and fail to capture required work, you eat it generally speaking.

Contractors, many of whom are small businesses or individuals, do this all the time. They also give estimates like "If we find mold behind the wall, it will be an extra ten thousand".

Medicine is also odd in that you have to pay for the doctors mistake. If the doctor prescribes a less effective drug, it has no effect and then after doing your own research find a better drug and get the doctor to prescribe that instead. You still have to pay for the first visit. If a plumber decides to go from plastic to copper pipe mid job, he doesn't get paid for the work he ripped out.

Multi billion dollar hospital groups, full of highly educated professionals apparently can't pull this off but the guy who poops in a bucket on the job site can.

The most insane part are the out of network professionals. It's like you have a deal with the plumber to fix tout kitchen for $100. But in the middle of the fix, you hear a surprise ring in a front door and it's a helper of the plumber that comes an does something. And the next day the plumber notifies you that you must pay an additional $500 for the other guy.

The hospital is reimbursed on a fee for service basis. Most (all?) countries use a fee for service model, but most countries also don't have for-profit payers that are incentivized to drive up the cost of care.

Exactly the same situation is in rest of the world, no patient is shopping around. just goes usually to closest/biggest hospital. Yet we don't have this tragic mess US has. So its not about shopping around, rather some other reason like regulations, wrong dynamics between hospitals and insurances etc.

You don't have better equipment nor doctors in US compared to biggest hospitals in Switzerland for example. Yet we have fraction of the costs as patients, and its not due to low doctors/staff salaries. Equipment is also top notch everywhere, new machines in all departments.

I believe that "closest/biggest hospital" is a choice in emergency. Or when it's something unimportant. Otherwise people tend to choose a doctor and clinic based on reviews or recommendations, or maybe years of experience. Even with a free healthcare you still have a paid private medicine and a free public one. And they have to compete which leads the price going down, because one side is always zero or close to it. Not like it's in the US where the direction is opposite as you don't have a zero side but only "unbelievable high price" side.

Even in relative emergencies. I'm in the UK. Years ago, my ex fell towards a glass door, and trust her arm through a thick glass pane, getting a nasty cut down her lower arm that exposed her tendons (I saw them... Not a pleasant anatomy lesson). After she was stabilised by the ER/A&E, she was told to come back in the morning (her arm was still open, but bandaged) to get properly patched up. Instead of going back to the nearest hospital, the following morning we went to the A&E of one an hour away with a good reputation for cosmetic surgery.

A&E can't turn you away. It gave her a few days of waiting in hospital (she was not a high risk patient, but they did want her available and under observation), but it gave her a leading specialist on hand surgery. And we walked out with no bill.

(and you're right - there'd still be the private options too, but in this case the NHS option had some of the best surgeons in the country in that field anyway)

I believe that in the end, it boils down to culture, with all the regulatory dysfunction and market dynamics acting as intermediary.

In the US getting wealthy seems to be almost implicitly well respected, no matter how you got there. At least if it's not obviously illegal. You found a tweak to squeeze more money from health insurances? Good for you, let them suffer for their apparent weakness. There's apparently still a threshold of where even success cannot vindicate the way to get there (that Oxycotin family comes to mind) but that threshold is super high. I believe that this threshold is much lower almost everywhere else on earth and that this has an influence on individual decisions on all levels. It doesn't even remotely make people elsewhere angels or something like that, but it's a little bit of friction in every decision towards "take what you can"

Switzerland is #2 in per capita healthcare costs after the US. US is $11k per capita and Switzerland is $7k per capita.

Countries like Finland (4.2k) and New Zealand ($4.1k) show Switzerland could be doing way better.

Maybe the pot shouldn’t call the kettle black?

https://data.oecd.org/healthres/health-spending.htm

Dentistry is paid for by insurance and is relatively cheap either way. Healthcare in the US is expensive for several reasons. Excessive paperwork and bureaucracy, unpaid bills, required service, 24/7/365 services, complex diagnosis, lawsuits, medical school, regulatory capture, etc etc.

Changing any one of them isn’t going to fix pricing. We really need to change several pieces at the same time and the industry really doesn’t want lower prices as that reduces their income.

I’m pretty sure most of this is also what, say, EU has to deal with. They most certainly have bureaucracy, unpaid bills, 24/7/365 services, complex diasnosises…

Some big differences: Without the equivalent of AMA lobbying Europe has a lot more primary care doctors per capita than the US. No long history of trying to get everyone healthcare without using taxation resulting in a pile of Rude Goldberg regulations that nobody understands. Regular use of cost-benefit analysis in deciding what procedures or drugs to pay for, now that the FDA has approved aducanumab it's going to be available to people even though it probably doesn't work and is breathtakingly expensive.

Single payer largely avoids unpaid bills and a great deal of bureaucracy around billing. This is true even in the US, just look at the VA’s costs. The VA is serving a very expensive population and it does so relatively cheaply for the US. At least in terms of services rendered rather than just per person.

The 24/7 comment was in comparison to dentistry. It’s tempting to compare getting stitches to getting a filling but inherent overheads are associated with an ER which must be added to the bill.

The United States leads the way in treatments and medical tech, but this gives me the impression that the US society is not benefiting as it could from that.

As someone who used to work for a company trying to get insurance to pay for medical technology, the US was typically the easiest and fastest country to get coverage in for both private and public insurance.

This seems poignant. The cost/benefit analysis does not seem to be aligned with the market. I suspect it’s driven purely by lack of qualified practitioners.

It's not. Physician reimbursement has been going down year over year since the late 90s. Each unit of physician work (relative value units, RVUs) is worth 50% of what it was in 1998 for Medicare at least, and most insurers peg their reimbursement at a specific multiple of the Medicare rate. Sorry, the insurance companies, PBMs, and hospital administration is to blame for the high cost of care, not the physicians who don't control how much they are reimbursed for each office visit or procedure.

Medicare and Medicaid are at best 50% of reimbursable amounts in most sub industries.

Also, while $/CPT code can go down, you can see more patients/day or alter your staffing ratios and other operating metrics to more than compensate.

Healthcare has some of the most "woo woo" hand wave-ey financial metrics around. Do a private equity quality asseatment on quality of earnings on "gross earnings" in most health care settings. Other than the Enron consolidations there can't be a more bullshit financial metric (heck entire area) under US GAAP than gross earnings. With that level of obfuscation (purposefull or not) it's no wonder you have almost full opacity into the cost chain.

If that’s true then why have physicians wages continued to increase for most specialties? Some have stagnated, but I wouldn’t say physicians are underpaid.

> example of the benefits of free market economy

Healthcare is rarely a good example of the free market. Medical decisions aren’t made by comparing costs between providers. And if you’re in rural America, you’re lucky if you have any provider. Price transparency would be nice, but maybe not as helpful as you’d like. Let’s say you’re in the middle of a rural area and the ER says you need stitches — but they cost $6000. What are you going to do about it? Are you really in a position to negotiate? Your choices might just be 1) get the treatment, or 2) go without.

Many things in rural areas cost more than they should. Usually on this forum we talk about the high cost of internet access and the lack of options, but medical is very similar in that regard. Services are hard to find, providers are covering a very large geographic area, and many costs are higher.

It’s not a good example of how a well functioning free market would work.

I’d go as far as to say the healthcare market in America is the opposite of a free market. Everything about it is anti-free, from the information asymmetry, to lack of local choices, down to an inability to even assent to participate in the transaction (due to incapacitation etc.).

It’s hard to even call this a market, let alone a free market. According to the Wikipedia entry on markets, “the usage of the price mechanism to convey information is the defining feature of the market”. It’s notable that in The American healthcare market, the price of your treatment is usually discovered after you’ve agreed to purchase the treatment (or it’s been administered without your consent). In fact, often it’s impossible to figure out what you will pay until after the fact due to how complicated answering that question is.

And even if it were a free market it’s debatable we wouldn’t want to keep it that way. In a commodity free-market of peas for example, a mismatch of supply price and demand price means that some people will pay a suboptimal price for peas while others will be priced out of the market entirely, and they will have to go without peas.

In a healthcare market, when someone is priced out they go without healthcare, which means worse and more expensive outcomes down the line. The old adage about how an irrational market can stay irrational longer than you can stay solvent comes to mind — a healthcare system motivated to maximize profit will price you out of the market longer than you can stay alive.

But that's exactly how a free market does work.

It's exactly what any rational person would expect from a corporate free-for-all designed for maximum extraction potential based on maximising political power differentials.

Good state-owned care smooths out the inequalities, so farmers in the middle of rural area will at least have affordable access to basic care, and more advanced care will be within easy travelling distance.

This ends up being far cheaper for everyone who needs medical care - which is basically everyone.

The only losers are profiteering shareholders.

Of course you still pay for it, but you don't pay as much. And you won't be bankrupted by bills for which you either have no cover at all, or limited insurance cover which still leaves you with a huge sum.

Healthcare is ripe with market failures - everything you are describing is well studied. Those who argue for a completely unregulated market, in my limited interactions, have not usually studied economics or the concept of market failures. Market failures are generally associated with public goods or government regulation.

To name a few with healthcare:

Information Asymmetry. It should be expected that a patient does not know what a Level IV emergency is and the complete ins and outs of how they are going to be charged. I'd argue that the industry has intentionally amplified this market failure. Furthermore, patients are often left with the final decision, but who is going to disagree with a trained professional on their required treatment? It's like going to a mechanic when you have no idea what's wrong with your car. You kind of are trusting the mechanic isn't taking advantage of you (and that is regulated). Or you have to reduce the asymmetry by learning about the basics of cars.

Medical research has the attributes of a public good: Non-excludability and non-rivalrous - when something is discovered it's generally known to everyone without dropping in supply and the information is available to everyone (yes the product which results is rivalrous and excludable in the same country, hence it works as a private good - but then that product has non-competitive markets).

Non-competitive markets with respect to rural areas are also mentioned in the article. Much like the issue with utility companies and broadband providers (the latter of which was shown to be a partial public good in the US with the infrastructure bill).

You've also got the Certificate of Need system, introduced in the Nixon years on the theory that if allowed hospitals to compete with each other it would lead to redundant capacity and thus higher costs.

And then there's the Medicaid reimbursement rates, decided by a committee using the labor theory of value rather than something sensible like cost benefit analysis and negotiation. And since it's illegal to charge someone else less than you charge Medicaid these tend to have a cascade effect.

Our healthcare system is a huge sequence of "make it so complicated that there are no obvious deficiencies" legal systems with layers of ad hoc patches its amazing it works as well as it does.

Normally I'm in favor of free markets but if nationalization is what it takes to clean up the current mess of a system we have then so be it.

The way Medicare is artificially restricted from driving down cost is atrocious. Medicare + Medicaid combined costs about as much per capita - NOT per patient - as the UK NHS. Except the UK NHS provides universal cover.

Now the NHS is an aberration and under severe pressure, but it is a good indication of just how inefficient Medicare and Medicaid are - and it's not that they can't do better, it's that they're legally prevented from using their market power.

My wife and her family are from Peru. It’s not uncommon for our relatives that are living in the U.S. to fly back to Peru and pay cash for procedures instead of doing it through their U.S. insurance.

The stitches are expensive mostly because of many regulatory factors that restrict the supply of medical services and drive costs up, with the "free market" component being in how much they can charge the patients. It's the worst of both worlds in the US.

I can tell you that you cannot freely open a clinic in Chile, and Doctors have the monopoly on many treatments that are delivered by nurses or other workers in Europe. Becoming a Doctor is not easy, and foreign Doctors must go through difficult tests before working for the public system.

Additionally, I remember that many supplies come from... the United States? So what regulations are you talking about?

Maybe you meant monopolies?

There's three areas that I'm aware of. Certificates of Need, which some states require before you can offer certain services (like MRI/CT scanning). Supply contracts, where a hospital has a pre-set price for consumables like IV solutions, scalpels, and bandages with a supplier. And advertising.

The Certificate reduces competition because they impose geographical exclusivity. If you want to buy a MRI machine for your clinic, you cannot if the state determines if your area already has enough of them. And if you file a Certificate with the state intending to buy one, your nearby competitors are likely to place objections to your purchase. This is because the machines are expensive and the other clinics want to ensure their investment gets paid for. But this process also ensures they're expensive because the machines aren't able to be built in volumes large enough to result in a cost reduction.

The supply contracts make things easier for the hospital, as they only have to deal with one supplier for an item or class of item. The price is known up front for the duration of the contract. But this also means that the hospital cannot change suppliers if another one has a lower price for the same item midway through the contract period, reducing competition. They also restrict choice by the doctors at the hospital - doctors have strong preferences for items like gloves because of sizing & fit, and the way they transmit feeling through them (thinness, texture, etc). If a hospital changes suppliers to one that doesn't carry their favorite glove, they aren't able to perform as well. And they can't bring their own into the operating room because of liability.

I don't know how many advertisements you see in Chile for medicine, but here in the US I would guess that a quarter of advertisements on TV are for them. All those ads cost a lot of money, and they're not being targeted at doctors, but patients: "Ask your doctor if {brand} is right for you"

The certificate of need business seems bizarre. I live in London, and the place is so crowded with clinics offering cheap MRIs it's ridiculous, despite the fact you'll get them covered in the NHS I'd you actually need them (literally the very first ad I found for MRIs offered them for 200 pounds).

The incumbent providers like the restriction on competition.

Well, I think then you'd agree with that we need the right regulation so the right incentives are put in place, and that at best would be better not to have the industry dictate the regulation, that in this case sounds absurd.

I was very surprised the first time I watched an open-tv US Channel seeing thousand of ads for prescription medicine. Which I believe are forbidden the countries I have lived in (CL, ES, DE)

We have more "regulatory factors" in Europe, and much cheaper treatment... Like 1/40 or so as much in this case...

WHen I stopped living in the USA, I realized that there is only one reason the USA is behind the rest of the developed world when it comes to healthcare, a social safety net and education. The USA likes it that way.

The American culture is one of rugged individualist pioneering cowboys who won't be told what to do, even if you're warning them that if they take another step they'll fall off a cliff.

I don’t think it’s the rugged individualism that’s at fault, so much as an emergent, insane incentive structure that has grown out of control. The confluence of big insurance, big hospitals/ practices, and regulatory capture have given us a completely warped system.

In just what century did you live here?

Definitely a common mindset, particularly of gen x and generations prior. I know I have it. Wouldn’t surprise me a bit if someone born and raised outside the us came away with this impression after living here for a while.

Honestly when I read the headline my first thought was “six stitches? Crazy glue is cheaper…”

>Honestly when I read the headline my first thought was “six stitches? Crazy glue is cheaper”

Unless you live across the street from the hospital it's just less hassle to do it that way. Any injury not worthy of an ambulance can be cleaned, glued and taped in the time it would take to sit in the waiting room while they serve all the people who are dying faster.

1979 - 2015, I finally escaped and haven't returned since, happily.

Regulatory factors exists in all mentioned countries. Medical services being restricted is not some kind of exception.

Not so sure for the impact of regulatory. Tons of other countries/areas have equivalent regulatories req, if not more strict, yet does not yield to absolutely insane prices.

Regulatory is there to prevent e.g. killing patients in a Therac-25 like events. When you have a too weak reg, you end up with things like 737-max situations.

Now maybe regulatory can also go too far in some niches, but the correct solution is not to blindly go in the other direction.

And anyway, absurd prices in cases of e.g. ER are most of the time explained not by the cost of medical supplies but by random attempts to purely extorts the patients: 6 stiches and a shot do not imply thousands of dollar of BOM, nor are physicians paid hundreds per minute. Look at the cost of covid vaccines if you want to know more realistic costs.

Exactly. What the US lacks is actually more liberal market in health. Less regulations and more competition.

When talking about regulations people usually mean regulating pricing and/or service quality but what actually needs to be tackled are the factors that limit competition, like: - process for opening new clinics/hospitals should have little to none restrictions - requirements for doctors (no doctors from outside can work in the US unless they complete $400k degree) - Drugs from outside countries should be allowed to be imported without FDA's approval

and so on

None of the other countries being discussed have any of that, and yet their systems work fine. So I don’t think the solution is there

The US is not a market-led economy in healthcare; I currently live in a country with universal healthcare and I make clear to people that when I disagree with universal healthcare it is not because I think it should be more like the US.

It is not uncommon in US going to the hospital and they giving you a list of options and prices. I don't know how to call that but definitely feels like a market.

BTW, I come from from a European country with universal healthcare and have been living in US for almost a decade and the feeling of someone making money of your health is at least weird. If I ever have some severe health issue no doubt I will go to treat myself to my country of origin.

EDIT: Also tired to hear about the problems of universal health care, specially with wait times. It is true that less important treatments could take some extra time but I have never seen a case where a fast intervention was needed and did not happen. I would say that common sense is something that works for universal healthcare. At least where I come from.

> EDIT: Also tired to hear about the problems of universal health care, specially with wait times. It is true that less important treatments could take some extra time but I have never seen a case where a fast intervention was needed and did not happen. I would say that common sense is something that works for universal healthcare. At least where I come from.

Almost all countries with universal care also have private options (Norway used to be an exception where offering private options for services available from the public healthcare system used to be practically impossible, but even Norway has relented on this though). Often the private options are also cheaper than the US.

E.g. for elective surgeries Americans might want to check London hospitals - many world-leading private hospitals for various conditions that are used to targeting foreign patients - especially wealthy ones - but still often charging much lower prices.

It's also not that unusual for those of us in the UK who can afford to go private to do so when we have some condition that the NHS certainly will treat but where there's a waiting list because it's not important.

And there are plenty of private insurers - only because the NHS offers a baseline, they're far cheaper than most US plans because almost all of them rely on the NHS as a first line and instead of picking up the bill for everything they only pick up the bill to accelerate care whenever there's a wait to see certain NHS specialists.

People need to consider the universal care to be the baseline. How much people are prepared to pay for the baseline over taxes will affect how fancy the baseline is, so if you want something better you'll need to pay. But at least it ensures everyone gets the baseline.

Can you elaborate on where you disagree with universal healthcare?

Your opinion sounds nuanced and, therefore, possibly interesting.

I’m curious what your proposal is, in that case?

Meanwhile, Congress passed a bill that's supposed to help with surprise billing. The Biden administration has started to implement it, but doctors and their representatives (Democrats and Republicans alike) claim the administration is not implementing the bill as intended and they are favoring insurance companies over medical providers by trying to keep costs down.

> “The Administration’s recently proposed regulation to begin implementing the law does not uphold Congressional intent and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and potentially force small practices to close thus limiting patients access to care,” Rep. Larry Bucshon (R-Ind.), who is a doctor and helped spearhead a letter of complaint this month, said in a statement to KHN.

https://khn.org/news/article/surprise-medical-bills-policy-c...

This shit makes my blood boil. Various vested interests, but mostly doctors, have stymied virtually all legislation (the ACA, Medicare and Medicaid being the notable exceptions) for a century.

https://pnhp.org/a-brief-history-universal-health-care-effor...

Those greedy doctors trying to protect their livelihoods from a bill that gives insurers an easy path to drive down their reimbursement when an alternate method of doing the same thing (New York's law on surprise billing) exists that does not have that same feature. I for one know that software engineers would certainly support bills that would reduce their pay for the greater good! Physicians are the only group that everyone expects to work for less and less money. It may surprise you, but most software engineers will have an easy time outearning the majority of physicians. It's not the 80s anymore. Doctors aren't super rich. Doctors aren't the ones who made you sick, but they are the ones who trained for 7+ years to take care of the problem. Shame on them for wanting to earn a living.

https://www.bls.gov/ooh/mobile/highest-paying.htm

In the states that use benchmarks similar to what doctors are suggesting HHS use instead of the agency's current proposal --such as New York and New Jersey — the report found costs rising. New York, for example, has a "baseball-style" system in which the arbiter chooses between the offers presented by the provider and the insurer, although the arbiter is told to consider the offer closest to the 80th percentile of charges. "Since the amount providers charge is typically much higher than the actual negotiated rate, this approach risks leading to significantly higher overall costs," the report finds. In New Jersey, billed charges or "usual and customary" rates are considered.

"When the arbitration process is wide open, no boundaries, at the end of the day health care costs go up, not down," Becerra says of the methods doctors prefer. "We want costs to go down. And so we want to set up a system that helps provide the guideposts to keep us efficient, transparent and cost-effective."

The system chosen by the Biden administration is expected to push insurance premiums down by 0.5% to 1%, the Congressional Budget Office estimates.

https://www.npr.org/sections/health-shots/2021/11/22/1057985...

The US medical system is incredibly regulated and constricted by the government and the rules and regulations. It is NOT a free market. An English friend who moved to the Bay area for work at Genentech had a wife who was a doctor from the UK. She could NOT practice as a doctor in California. This is deliberate by design. The AMA restricts the number of doctors to prevent their incomes being reduced.

The third party payment system of medicine is both directly paid for by the government and subsidized by tax writeoffs for the private insurance industry (which is tied to employment).

And meanwhile during a pandemic majority of Americans supported Medicare for all. Yet the corporate politicians are against it. The performative art of the "squad" was at full display when they had a chance to force the "Medicare for all" vote and passed on it.

https://www.opindia.com/2020/12/jimmy-dore-vs-cenk-uygur-dem...

https://www.businessinsider.com/aoc-rejects-left-wing-calls-...

https://thehill.com/hilltv/what-americas-thinking/412545-70-...

We deserve what we vote for.

Yep, and the same shits go around telling everyone to get an ambulance instead of Uber to go to the hospital and go to the ER instead of urgent care for certain symptoms. Fix your fucking system first.

Even I avoid the ER because of costs.

> This is the kind of things that show how inviable is a market-led economy without proper regulation.

The medical industry is highly regulated. I can't just go open up a practice giving people stiches. I would need a whole slew of certifications in order to do so. That's why this situation in the US is so absurd. The market is regulated to limit the competition at the expense of the consumer.

In the U.S. the "free market" is mostly a myth.

$400 still sounds high, to be honest.

The ER is quite expensive to run, they’re designed to handle the riskiest kinds of situations.

Imagine how expensive a software dev team would be with 24/7 work, and full cycle scrum sprints every 72 hours to allow for constant pivoting, with injects from one to a bus load of product owners.

I paid $400 for a plumber to do 30 minutes of work this week.

A doctor has more training and a lot higher infrastructure costs and overhead, and thus a higher hourly fee.

Same thing happened to me with a plumber 12 years ago.

I spent a couple hours on YouTube and now I can solder my own copper pipes, install a new toilet and anything else I need.

Even being a software engineer I couldn’t compete with the hourly rate of a plumber so it makes financial sense for me to do the work myself.

But plumbers have to deal with a lot of nauseating stuff. "Amount of nauseating substances you have to deal with" should be a huge factor in pay rate.

What do you think doctors do? My last visit involved their fingers, a glove, and my butt.

Okay, so a $200 surcharge every time they have to deal with butts. $100 for urine, $50 for vomit. Charge it to the insurance anyway, they're used to paying $40000 a day for a hospital bed, they can pay $200 for dealing with a butt.

Plumbers have to deal with the aftermath of butts MUCH more often and they don't have the luxury of someone's insurance they can just throw arbitrarily high charges to.

You realise there’s medical professionals who deal with poop right?

There’s also the whole ‘all your clients are sick, some are contagious’ thing.

I’m not saying america isn’t insane, but to try and pretend plumbers have it far worse isn’t quite accurate.

Okay, so pay those poop-doctors double salary? They're basically gastrointestinal plumbers.

doctors are paid roughly equivalent, and the cost of healthcare is substantially lower in other companies, so I’m not really sure what you think you’re solving here, but I don’t see your plan ever working either.

And yet ironically, in the US at least, there’s a decent chance that plumber actually makes more than a physician.

Unlikely, but if he does it’s because he’s the “owner of a plumbing business” not just a plumber.

Possibly upto a point, if you factor in that the physician has to contend with paying back $400K in loans and $1M+ in lost income from not working during earlier years in life.

Yes, and it would be even more expensive in Germany. But in both countries the insurance covers normally 50% of it, wherever you go. If not all. (Other sickness are covered normally 80% if not entirely whatever insurance you have)

What are you talking about? As long as you are not private insured - which is not difficult to do usally - if you have a job you are insured (a percentage of your pay is used for insurance, if you study you are insured (90 eur) or you can join on your own for 200eur/month depending on your income if you are working on your own.

You pay nothing for ER, 10eur/day for the hospital and a few eur for medication - but nothing even in the range for 50% or 80%

dental is also covered to a large degree but if you want state of the art you have to pay the difference yourself - but you can also add a private insureance for that for 100 to 300eur/year to have everything covered.

you can still fall through if you can't pay the monthly fee - but emergencies are also free even if you don't pay.

private insurance can be expensive but should usally cover also everything.

Did you actually read my comments in this conversation? Are you aware that in Germany clinics have different prices than the ones you pay after insurance? I have always talked about prices before insurance, which is what I'm arguing looks completely out of place.

I'm public insured in Germany and no, dental is not really covered, I had to pay my routine treatment last time at the praxis, and it was not cheap.

Do you know that if you don't have insurance (which is however mandatory in Germany) you get an actual bill for the medical services?

Yes, the price before insurance is generally higher, but reguated by the public insurance. See one of the price catalogs here: https://www.g-drg.de/aG-DRG-System_2021/Fallpauschalen-Katal...

You do not need to pay extra for dental if you choose the most basic treatment. Most people like their dental work to look like their natural teeth which does not count as most basic. That is why you had to pay, but only the price difference to the basic treatment.

And, of course, the doc likes to sell you some extra treatment (say "professional tooth cleaning") which will make her/him some extra money.

Same for glasses. The most basic option is free. If you don't like the coke bottle bottoms then you will have to cover the difference yourself.

I misunderstood your comment then. Sure what is billed is a different thing. Sorry.

For the dentist: They often bill you for stuff that is covered but it lucrative to add something to the bill.

Would be much less in Taiwan for example. I don’t know exactly but I’d have to guess $50 USD? I’ve been to clinics that charged about $15-30 for a doctor visit (cash price as a foreigner—Taiwan has national healthcare but they can’t charge to that for me). ER would probably be double that.

It’s not like you’re taking up a hospital bed. It’s a sew up and show you the door operation.

@garmaine I'm talking about the one the most prestigious clinic in South America in Santiago [1], and that's before insurance. I never paid that myself, because it was covered by the insurance.

[1] https://www.clinicaalemana.cl/

Marginal vs fixed costs.

Free market works fine, unfortunately like tuition prices the government got involved and prevented what the free market is good at and driving down prices. Fortunately now there a new price transparency laws which the full the effects haven’t been felt yet and are a step in the right direction.

When free market doesn't work, free market advocates have their solution : there wasn't enough free market, so we need MORE free market.

A free market wouldn’t be dumb enough to give a teenager a loan for 100k. That idiocy is reserved for the government.

Hence the free market would have excluded any teenager who doesn't have rich parents from higher education. Hardly a good thing.

Free market brings prices down and quality up. The government tried to ‘help’ 50 years ago and now the prices have become so distorted that without government help you would need to be rich to go to school.

People like you think the government should solve a problem that they themselves created.

> Free market brings prices down and quality up

In theory, but in practice there are many markets where that simply doesn't work, mostly due to natural monopolies, such as any type of infrastructure, healthcare or education, where competition is impractical or impossible, equal access for everyone is extremely important, and costs are high.

I think free market could work with education. It is really a question how to verify the results. That is how should degrees be granted. Which is rather complicated issue as there is way too many ways to cheat.

Still, nothing really stops competing methods and prices for teaching to competing levels.

Our mostly private health care system is twice as expensive as the social systems in other developed countries because the government got involved?

By what fraction will the new set of tweaks have to shrink costs to pay for the last 30 years of the private health care market's failure to deliver on its "more efficient" promise? Remember, it has to cut them by 50% just to break even, and it'll have to go further to make this experiment worthwhile. A lot further.

Spoiler alert: it won't even get to 50%. It won't even get close to 50%.

There already is a massive public healthcare system in America called Medicare and Medicaid which is the root of distorted prices. The lack of price transparency adds fuel to the fire and allows those prices to stay high without any upfront awareness given to the end consumer.

A lack of price transparency is indeed deplorable, but it isn't the root of the problem. The root of the problem is that demand for emergency treatment is inelastic. Inelastic demand curves result in wildly volatile prices. And when the service is a basic human need rather than a luxury, to prioritize a free market solution is to prioritize the market over the human. Markets must operate for the good of people, not the other way around.

Price transparency is shifting deck chairs on the titanic. I actually do think the new chair arrangement is a notable improvement on the old one -- but in an industry with unaddressed tectonic issues, it's not going to right the ship.

I might be wrong. Maybe price transparency will lead to a 50% reduction in prices in the next few years. I doubt it, though.

When I got my tonsils removed my options were the $75k surgery at the private hospital, or waiting 3 months at the public hospital. I actually stopped consulting and took a job so that I could get insurance, and had the surgery two weeks later.

A few years back I broke my wrist while bicycling across England. I was patched up and casted a few hours later, I think the bill was about $200, as a foreign tourist. It wasn't even enough to cover my travel insurance deductible. This would have cost me about $5k in the USA.

I agree that the free market works fine, for those who run the market.

The free market didn’t make your operation 75k. The government giving a blank check to hospitals and the lack of price transparency did that. Both are as far from the ‘free market’ as you can get.

Sure, whatever. Shit doesn't happen in socialized countries. The only libertarian countries that ever exist are that short vacuum of power when a banana republic dictator fails and the new warlords haven't chosen a new dictator. But yeah, sure, can't criticize something that doesn't exist. Good argument strategy.

Weren’t your tonsils a pre-existing condition? How did the new insurance cover it?

I lied to my doctor to an extent, and he lied to the insurance company to an extent.

All you have to do is ask a doctor "Please don't put any of this in a file until I have insurance next week". It doesn't mean anything to him to add the dates later. It's in his best interest, otherwise he won't get the cheddar.

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