A new report clarifies some misconceptions about the U.S. medical system
theatlantic.com
theatlantic.com
That one government action has ripple effects throughout the economy and almost all of them are negative. It concentrates economic power in big agribusiness instead of farmers, because it means that chemical/bioengineering companies like Monsanto can wield huge economies of scale across the one crop that is most economically viable in the U.S. (because it's subsidized by the government). It drives local farmers out of business because they can't compete with the giant agribusinesses. It makes the U.S. agricultural system less resilient to drought and blight, and more dependent upon petrochemical fertilizers.
And then it also makes it far more economical to make food products with high fructose corn syrup, corn-fed chicken & beef, cornmeal, and corn starch, all of which are phenomenally unhealthy for you. This is why poor people eat at McDonalds; because of the subsidies, corn-fed beef & chicken and soda made from high-fructose corn syrup are much cheaper than healthier alternatives, and so that is all poor people can afford. Then they get fat, and the rest of society bears the burden for their medical and lost productivity costs.
Fat people do not need HFCS to become fat. They need calories. Some people suggest that HFCS may make those calories less satiating than calories from fat, but they don't mention other types of sugar. Any sugar when eaten in excess is harmful. Sugar from honey or sugar beets or sugar cane is going to cause harm if you're drinking six litres of soda a day.
The Economist puts a UK Big Mac as cheaper than a US Big mac. What are our subsidies that make the burgers so cheap, if we don't have cheap HFCS?
http://www.humuch.com/prices/McDonalds-Big-Mac-Meal/______/5...
http://www.census.gov/compendia/statab/cats/agriculture/farm...
829 is also illuminating. Of 96,074 corporate farms, 85,837 are owned by families (several thousand of those family owned corporations having more than 10 shareholders). Of the corporate farms that are not family held, 9,330 have less than 10 shareholders.
Acreage is also revealing (828), family farms have ~ 5 times as much land as corporate farms. It's also sort of easy to make the case that less than 5% of the corporate acreage is likely to be the pernicious sort of farm you are talking about.
It makes for a nice narrative, but it isn't all that true.
Just stop being fat.
Obesity doesn't explain a $800 knee MRI or $4K ambulance ride. A californian hospital billed us at $3.7 per second for a broken wrist.
Your brother, not fat people, is making healthcare expensive. This is so freaking obvious I'm starting to veer into conspiracy theories territory failing to explain this craziness: they'll start suspecting "mongolians and puerto-ricans" as factors before they'll notice this enormous elephant in the room. Every US city has a neighborhood where "doctors live". It's sickening.
Also, ask your brother what he thinks. I have a few friends in healthcare and they're very open about it (it's hard to deny if you know their lifestyles)
Cost is explained by a great variety of factors, some of which you have identified, but many of which are much more subtle.
Regarding other facets of healthcare costs, some kinds of medicine and equipment are just flat-out expensive. Figuring out what costs are largesse and what costs are justified is tough, and made somewhat more difficult by distortions to the market by insurance and medicare. I'm not saying insurance or medicare are not the best solution (I don't really know) but I do know it affects the market pricing mechanisms.
Cost-controlling is a huge topic in the healthcare industry right now. Nobody disagrees that the costs are too high, but some things are worth paying for more than others. I think there are other places to look before the docs.
Moreover, I said "heathcare providers", not "doctors". Every piece of medical equipment, from an artificial joint to a scalpel, goes through a lengthy list of middlemen each making a healthy margin.
Walk into the oncology clinic (the same ones who accept donations from various "X to cure cancer!" events) and take a look at price of the hardwood they put in. That's your "cure cancer" money and it has nothing to do with "doctors should cost a lot".
Healthcare lobbyists is the problem, but I'm just pointing out the easiest signs everyone can see. It's not rocket science: if you think obesity is the problem, look at the cost of giving birth. If you think insurance companies are the problem, try to get an MRI independently. If you think cost of education is the problem, look at the degree a jet-owning medical equipment salesman holds.
[1] http://en.wikipedia.org/wiki/World_Health_Organization_ranki...
Also, don't assume anything about my experience with healthcare-- because you're wrong. I'm not sure why you'd swing wild with that remark anyway.
http://www.theguardian.com/commentisfree/2013/nov/11/support...
Furthermore, health insurance is used as payment system as opposed to insurance. Adding layers of bureaucracy to a system serves to only inflate the cost of that system.
There is a confluence of factors involved in why the system is the way it is. It is not simply obese people or doctors who are at fault here.
It's extremely expensive to go through the medical education process in the united states (both in terms of time and money). Columbia medical school is over 70k/year and they offer no financial aid. For some specialties that's 4 years undergrad, 4 years med school, 4 years residency and 3 years fellowship with some extreme hours and lower pay before you actually begin work.
The higher incomes some specialties have are in response to the cost of education and the cost of time (basically your entire twenties). Without this only the obscenely wealthy would be able to even consider medical school since the up front cost would make it prohibitively expensive (it's already bad currently).
The American health care system is complex - as is the reason for its extreme listed prices (insurance companies don't actually pay what's billed). I don't think it's valuable to draw strong conclusions/blame based on a dramatic oversimplification of it.
EDIT: oops, bad math. But 3.70 per minute is closer to the actual cost I paid. I can't say exactly because I didn't have a stopwatch going.
$3.70 per minute is $222 per hour. $3.70 per second is $13320 per hour.
What I know is that when I'm sick and/or injured I want a well paid doctor who has spent 14 years in training taking care of me.
The reason your ambulance ride was 4k is because anybody who is even remotely able to pay subsidizes everyone who doesn't. Healthcare is systematically broken in this regard, here in the US because there is no universal coverage. Not because there are neighborhoods where doctors live.
Your gripe is with the ever increasing administrative burden on doctors and the burgeoning bureaucracy. Doctors and other healthcare professionals are worth every penny.
Actually, what's sickening is ingrates like you who begrudge experts their due.
Also, ambulances are expensive vehicles crammed full of expensive technology and two expensive well trained staff.
When you're lying on the asphalt in a pool of blood you don't want any old flatbed with a couple of burly blokes turning up. Sure, they can heave you onto the back of the van and get you to ER quickly, but will you still be alive when you get there?
(Having said that, $4k seems expensive. Average UK ambulance cost is a couple of hundred pounds)
Many careers cost a great deal of time and money to get into (the cost of schooling is a huge issue, but a totally different discussion). Most of those careers make no where near the same sorts of salaries as MDs expect to make. The sciences in general have all of the same issues you mention. Doctors make obscene salaries in our current society (though not necessarily historically). It is disingenuous to say that doctors "deserve" these sorts of salaries. Doctors in other countries do not make the same sort of inflated salaries as US Docs. [0]
Again, while I agree that the system in general is broken, it is not sickening to point out that doctor's make obscene salaries.
[0] http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-...
Goods are priced based on their value to the consumer, not based on their cost to the manufacturer.
I don't know how health care is priced, but the idea I should internalize sympathy for the education burden on a doctor into the cost of my bill is asinine.
(1) Have you actually asked them? (2) So you're saying that they'll blame someone else, rather than blame their own bureaucracy and inflated salaries.
2. I can agree with you on the bureaucracy thing but when you get sick you're gonna want the best doctors working on you. I don't begrudge doctors a single penny they honorably and legitimately earn. 14 years of school and hundreds of thousands in debt? Ya, you do that and get back to me.
Your answer begs the question. Also, US doctors earn a higher multiple of the average salary than doctors in other Western countries do, while not providing measurably better patient outcomes.
EDIT (after question was answered) I do agree that obesity is the leading problem with healthcare! I'm just curious about the problems of alcohol or MH in emergency care settings. They're significant in the UK.
Honestly, obesity is a root cause for so many preventable illnesses. All it takes is moderate diet and exercise and you'll be set.
Unfortunately, as we learn more about obesity, it's becoming increasingly clear that once you are fat, it is very difficult to ever lose the weight and keep it off for a significant amount of time[1].
I don't know what the solution is, but being overweight, especially "on the way up" is something that should be taken much more seriously.
1. http://www.nytimes.com/2011/10/27/health/biological-changes-...
But really, it's quite easy to stay fit, if you want it. First thing you do is eat less (can't emphasize it enough). Second, eat home food and cut all the junk. And lastly, stay active: bike, swim, hike, whatever. No need for fancy diet programs.
The US gov't itself already spends more (per capita) than does the Canadian gov't. Is the US obesity rate much higher than Canada's? Have a look: http://en.wikipedia.org/wiki/Obesity_in_the_United_States
Pass a law that requires all payers to pay the same rate for the same service, be it an insurance company or an individual paying out of pocket and the system would get fixed in short order.
In many cases, the insurance agent who sells the policy gets paid the roughly the same amount as a primary care physician for looking after a patient. Only one party here is actually doing needed work...
If you did what you suggest then medicare would have to pay more (probably 50-100% more), which would necessarily increase taxes.
This is not necessarily a bad thing, just keep in mind all the unintended consequences.
Who do I believe, a blogger from The Atlantic who seems to be misinterpreting the data he cites, or a peer-reviewed scientific publication?
Headline: Obesity, not old people, is making healthcare expensive
Article: contains no occurrences of the word obesity
I thought this might be because the US system has much more support for people over the age of 65, and thus pushes prices down, but later on in the article they say
> Though it often may feel like out-of-pocket expenses are growing disproportionately to the cost of healthcare, Medicare, Medicaid, and federal employee plans have actually picked up an increasingly larger share of the tab.
The article makes some assumptions.
> The patient wants to see the best doctors and get the best treatments available,
Not necessarily. Many patients don't want the best, they just want protection from the worst and they want "good" or "excellent", but they'll include other things. "How convenient is the hospital for people to visit or for me to get after care?" is one example.
The article title is annoying. The article doesn't explain why obesity is driving up costs, and doesn't do a good job of showing that obesity is driving up costs. The abstract doesn't mention obesity, but says:
> Three factors have produced the most change: (1) consolidation, with fewer general hospitals and more single-specialty hospitals and physician groups, producing financial concentration in health systems, insurers, pharmacies, and benefit managers; (2) information technology, in which investment has occurred but value is elusive; and (3) the patient as consumer, whereby influence is sought outside traditional channels, using social media, informal networks, new public sources of information, and self-management software.
The problem, by one analysis, is that patients have no incentive to weigh costs against benefits. That's a tough task in any case, and pushing it off to the insurers makes it harder, as the insurer has less information than either the patient or their doctor about their individual case. The result is that neither patients nor (often) doctors know what the services cost.
In fact price information has been so effectively removed from the system that in some cases nobody knows what the service really costs. tptacek posted a great example: http://news.ycombinator.com/item?id=4465845
The purpose of the mandatory minimum copay is to force price information back into the system. When patients have to pay some part of the price of every service, they will therefore have to know what those prices are.
All that said, there are obviously some questions and problems to be dealt with. For starters, what's the formula for how much people have to pay? On the large end, I would suggest something like (price in dollars) ^ 0.7. This means for a $10k service, the copay would be about $600; for a $100k service, about $3000; and for a $1M service, around $16k. Those numbers feel reasonable to me: big enough to make most people think twice about choosing a six-figure intervention, but not an absolute barrier if there's a good medical reason.
On the small end, though, that formula produces numbers that are arguably too large. A $200 service (if there is such a thing? maybe in lower-income rural areas) would have a $40 copay by that formula. This risks discouraging people from getting preventative and urgent care that they need. To correct for this we could simply subtract some fixed number from the result of the above formula. I'm not sure what the right number is, but somewhere in the $40 - $80 range, I would guess. (This provision could also be subject to means testing.)
Probably when I say "mandatory" what I really mean is "the government provides incentives to make plans with this property significantly cheaper than those without". I don't care that rich people will circumvent the rule if they want; I just care that most people are on plans with this property, so that, as I say, price information is forced to flow again.
"Why are you re-canularising me? Why am I being charged for this extra un-needed canula procedure? Just leave the old one in" etc. Doctors can assess the research, and can decide whether the risk of infection from old canulas balances the risks of new canulas, and whether the cost is worth it or not.
Here's a radio programme (no longer available from the BBC website, but may be somewhere else on the Internet?) about an Indian hospital that does a lot of work to drive down costs. http://www.bbc.co.uk/programmes/b039yz53
http://www.bbc.co.uk/news/health-10837726
> "We believe that the only way is to build large hospitals - 100 or 200 beds are not going to be the solution for the current world health problem. We need to build large hospitals where hundreds of operations are carried out every day."
> And here in Bangalore, the theory appears to work. Despite the huge volume of operations, mortality rates are comparable with or better than those in Britain and the US, and costs are much lower.
If people have a minimum copay, they're far more likely to hold off until treatment is urgent—and, thus, much more expensive.
http://healthcarecostmonitor.thehastingscenter.org/louiserus...
http://www.nytimes.com/2008/10/07/health/views/07essa.html?_...
http://www.newyorker.com/archive/2005/08/29/050829fa_fact?cu...
"For that matter, when you have to pay for your own health care, does your consumption really become more efficient? In the late nineteen-seventies, the rand Corporation did an extensive study on the question, randomly assigning families to health plans with co-payment levels at zero per cent, twenty-five per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars. As you might expect, the more that people were asked to chip in for their health care the less care they used. The problem was that they cut back equally on both frivolous care and useful care. Poor people in the high-deductible group with hypertension, for instance, didn’t do nearly as good a job of controlling their blood pressure as those in other groups, resulting in a ten-per-cent increase in the likelihood of death."
- Your old co-worker
Right now if you think your local gas station or restaurant is way too expensive or slow or otherwise incompetent and you'd like to build one right next door that will charge less, steal most of the business and possibly drive the older one out of business, you can just DO that. But not with hospitals. In most states you aren't legally ALLOWED to build a new hospital or expand an old one unless the area where you're building it is deemed "underserved".
Sure, fix the costs (especially with IT/technology in general, as those on this board can probably have the biggest effect on that), fix the insurance industry, and let's have a serious look at the food industry while were at it - but on an individual level, giving exercise a try will probably reduce our health costs in the long run and make us feel better in the short run.
One thing to note is that there are many organisations who represent the elderly and they have political power - certainly in the UK, older people vote so you see laws that benefit them sometimes to the detriment on the young.
Consequently, if you can pay, you get to the front of the line, and if you can't you'll get one eventually, but you won't die.
They always roll out the little old ladies in wheelchairs when it comes to healthcare reform.
That's such a great comfort when you are in excruciating pain and can't walk. I think that should be the motto of the NHS "at least you won't die". Aim high.
Actually it's not the little old lady problem. I did a documentary on healthcare in the UK. One of the patients suffered from severe rheumatoid arthritis, a serious autoimmune disorder, she was told it would take 6 months to see a rheumatologist. She had the means to pay for private care and saw the same doctor within a week. You see arthritis which you probably don't have and obviously don't understand comes in many for from the less complex osteoarthritis to forms that have many nasty sequelae such as lupus or psoriatic arthritis.
I have worked in healthcare for 20 years and my wife about the same but she has worked more internationally. In countries with state run healthcare many times newer treatments such as cancer drugs are not available.
Flawed though it may be I will stick with US medicine.
Again: rheumatoid arthritis does not kill you.
many times newer treatments such as cancer drugs are not available
Good that you say that. In many countries to gain approval the manufacturer needs to show a benefit over what is already on the market. Whatever was there was new, but it didn't prolong survival or improve quality of life. Why should the public pay for something very expensive (because it's still under patent) when something equally good is available for much less as a generic?
Suppose a bunch of people get fat. What are the chances that they, after the fact, convince themselves that fat is okay?