The Cost of My Mother’s Cardiac Care in the United States and India
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It has been a few months since I have seen a doctor, but I still receive some new goddamn bill every other day. They are usually cryptic and leave me wondering what the hell they are for, and why they were not just presented to me on the day of the test. Don't even bother asking anyone what a procedure costs. Hospital staff will redirect you to someone who deals exclusively with insurance (completely unnecessary if we just had simple bills like any other transaction FFS), and the insurance people don't have enough specifics to ever really give you an answer, not to mention the time it will take waiting on hold etc. When you are getting multiple procedures, its just not worth the time. So you are practically forced to go in completely blind about potential costs.
To top it all off, my insurance coverage has expired as I recently graduated. So my options are to either pay $600 for 30 days of medicine that I need, or get the exact same medicine shipped to me from India, for $10-$20. They produce it by the millions in blister packs. This should not be so difficult! If we just had realistic prices in the first place instead of inflating them and bringing them down with insurance, this crap would not happen.
And don't even get me started on "pre-existing conditions". What that means for me is constantly lying to doctors and being unable to give them a complete medical history - otherwise I'll have f* "pre-existing condition" stamped on my head and never get sane rates again.
I fail to see why health care is not treated more like a series of simple business transactions in an economic system instead of this colossal mess.
/rant
Also, the optimizations in health care over the last couple decades actually have gotten it to cost more overall, mostly due to processing overheads and bureaucracy.
When it comes to getting multiple bills, part of that has to do with their standards with insurance agencies. Usually you have CPT (R) codes, HCPCS, ICD codes and so on (at least in the US, international places do not use CPT often.)
There is professional billing, which generally involves physicians or specialists time and expertise. While hospital billing involves staffing, reduction of capacity (like taking up a room or a bed), and all supplies, materials, and labs performed while admitted.
Another thing that is standard in the industry is that it actually costs more to consult someone than to refer a patient to them. Part of this has come due to insurance agencies being more supportive of consulting which means that the specialist can benefit more patients with less responsibility transfer and time.
The entire healthcare industry, in every country, is full of people who love to play fast and loose with other peoples money.
But that doesn't mean that people play fast and loose within the healthcare industry.
Sure, the VA [1] spent so many resources (an unrealistic amount..) on a single component, namely scheduling, that people can easily think this on top of the already existing costs.
Wasn't there a post at one point about how working at microsoft was like being on antidepressants? It's probably a magnitude more than that at the government.
[1]: http://en.wikipedia.org/wiki/Veterans_Health_Administration_...
As far as I can tell, the inflated prices (that almost no one pays) are mostly just so the hospital can report how much they're "losing" treating uninsured patients who can't pay.
Actually, it's because they lose money (on average) on patients on public insurance (Medicare[0] and Medicaid patients), so they need to charge private insurers more to cover the gap[1].
Insurers negotiate "discounted" rates with certain "preferred" hospitals in exchange for sending them more volume, but in this case "discounted" means "still overpriced, but closer to the actual marginal cost". The other private insurers still pay the exorbitant rates.
This is why hospitals are completely willing to lower your bill if you are uninsured and paying cash if you ask - they don't care about the money they're getting from you; they care about the money they're getting from the private insurers. The amount of money they make off of patients who are uninsured and paying out of pocket is negligible in this calculus.
Many hospitals are not at all secretive about this; executives talk about this pricing model fairly openly.
[0] For simplicity, I'm ignoring Medicare Advantage plans here.
[1] The ratio of this is HIGHLY dependent on the patient demographics of the particular hospital, but the general trend holds throughout.
I went to a single visit to a hospital once and after the treatment, I got 4 different bills. I was amused why I was getting bills from places I had no idea about. Then I realized each entity had a different billing department - the hospital's bill, the doctor's bill, the tester's bill, etc. all related to the single visit to the same hospital.
I had to call each of the 4 departments and deal with insurance. It was a nightmare!
My mom had some big treatments last year. My dad is a probably-undiagnosed-autistic guy who loves spreadsheets. He set up a spreadsheet for every single visit, correlating exactly how much was paid, exactly how much insurance (including Medicare) paid, and when each provider was marking the bills as paid.
He's retired, so this was his full-time hobby.
He still got continuously yanked around by every single provider, some claiming paid in full (which my dad filed dutifully in a binder) and then later asking for more money.
It's a freaking mess.
[1] Of course there are more than 2 choices.
I've never needed any major health care from them, but I have a parent that has had both hips and a shoulder replaced with Kaiser who had a similarly simple experience.
I don't know if it's a good idea. I have a related anecdote: My mother forgot (or omitted) to mention a pre-existing condition when she contracted a mortgage insurance. She died a few years later from causes totally unrelated to the pre-existing condition. Somehow, the insurance company found out and legally canceled the insurance.
I don't really know how all that works but just curious - is it documented / can they prove that the pre-existing condition wasn't mentioned at that time? Sounds pretty convenient for the insurance company to purposely "forget" something like this and then abuse that information when the time comes since, unfortunately, the person who could argue it is no longer alive.
First, I would delete the sentence after this if I were you, since it could come back to haunt you legally[0].
Second, unless things are different for foreigners in the US (which AFAIK is not the case), this is not how pre-existing conditions actually work (anymore), post-ACA.
[0] (I am not a lawyer, I am not your lawyer, and this is not legal advice.)
> So you are practically forced to go in completely blind about potential costs.
This (price transparency) is actually the real problem more than the sticker prices themselves.
If patients had the ability to know expected prices beforehand, market forces would work to bring prices down. As it stands, we have a very awkward situation in which insurers compete to keep premiums down to attract customers, and therefore negotiate lower prices with providers, but patients are completely blind to this entire process and are unable to "vote with their wallets", because the prices that patients pay and the prices that insurers pay are not always directly linked in practice.
If patients knew to ask. Really. If you are covered by insurance (including medicare/tri-care/etc) you won't get an answer. But if you are paying out of pocket (and most hospitals require credit if you are doing something serious - like open heart)you can negotiate the price.
Let me say again, the hospital will negotiate. The doctors and labs (not done in the hospital) are another matter.
Also, if you see an aspirin on your bill costing $75 you need to call. You'd be surprised how effective this is. Most Americans never question the price of anything. Even cars these days people take at face value.
Of course, if you in the ER with chest pain, I'll admit, the last thing on your mind is the bill. And the hospitals know that.
So what's the lesson here? In America have insurance. Even if you are 20 years old. A simple care wreck can destroy you financially. You think student loans are bad? Try a drug overdose. Or a heart attack. Or a fractured back ( a car wreck). If you young, insurance is cheap. Dirt cheap.
This would only really work if it were legal for hospitals to compete on price and for better/cheaper hospitals to expand and capture extra business thereby driving worse/pricier ones out of business. Which it's not. In any other industry if local providers provide crappy service at ludicrous prices you can open a competing service across the street and steal all their customers. And companies do just that - you get competing gas stations and competing burger joints right across the corner or across the street or just down the street. But hospitals generally need to PROVE their entry to the market WON'T harm the existing players, or they aren't allowed to open or expand facilities. Which means no price competition, no price wars...and no transparent pricing.
With open pricing and data a market based health system might work. Maybe.
Of course, Canadians don't pay out of pocket for the vast majority of insurance things, but it even extends to other non-covered services like RMTs, dentistry, etc. Private insurance may not cover some specific things (like white fillings on molar teeth), but you never have to wonder what the prices are or how much you'll end up paying if you say yes.
The best part is that I guesstimated the cost of the procedure in Colombia. But even if I tripled my guesstimate, it would still be cheaper to fly!
For time-insensitive or elective procedures, you can and should go abroad. The real cruelty is people who don't have a choice--emergency situations, cancers, etc. They're trapped in our hideous system and often have to choose between their life savings and a lifetime of debt, and dying.
Our American approach to healthcare disgusts me. Every time I think about it I get filled with rage.
IMO, The biggest problem is really lack of transparency for this stuff. If a hospital takes government money (and pretty much every one of them does), it should be required to publish its rates like a utility does.
"Sir, this is my duty. There are poor people right outside, your money would really help them."
As I talked to my relatives about what I experienced, I learned that Indian medical staff see their job as their dharma (duty), a belief that stems from their medical training and originally from the Bhagavad Gita, a religious text that is central to Hinduism. If I had to state a particular reason for the quality of Indian medical treatment, that's what it would be - that they consider their jobs a sacred duty. When someone truly believes that their job is a sacred duty, they will do it with a passion that cannot be artificially reproduced by a huge salary or per-patient compensation.
Being polytheists Indians have a God of medicine too. He is called "Dhanvantari" a man with a pot of potion of immortality. I have seen his life size statue in many private Hospitals.
Medical industry is only lucrative to foreigners coming to India because of the foreign exchange factor. Otherwise its the same this there too. Not the kind of Insurance company mess I hear happening in the US through folks on this forum, but there similar things here too.
To start with most doctors will write down a series of tests even if they are dead sure of what the problem is. These even include stuff like viral fever, common cold. People fall for it because dengue and typhoid has been always been for a while here. We have a famous test called 'basin test'- basically it means collecting the patients blood and draining it in the basin, because every one is so sure that the patient has no issues there is hardly any point wasting time and resources testing.
Doctors purposefully prolonging treatments to keep the consultation fees coming is pretty common. Most physicians close to your home, where you would generally go have a deal with a the nearest pharmacy for commissions in exchange for writing down drugs which are only available in the pharmacy. Same works for writing down tests. Although these days 'polyclinics' are getting pretty common, the doctor will generally have a small test lab at the clinic and will to makes some money through that too. I even know doctors who run diabetic camps, thyroid camps and obesity camps and what not just to get patients to clinics because drug companies want some free marketing and trap more patients to believe they have some disease which they don't.
Medical education is expensive in India. Sure you will get respect but even for an ordinary Indian, overall tuition and capitation fees means the only way for them to recover their investment is through either cheating or dowry.
The bigger problems like are a little different, but even there mishandling of cases and purpose full wrong treatment to pump up the hospital bills is pretty common.
Its the same everywhere. Its about greed, people in US and India are no different. Greed works the same way in US the way it works in India.
This was true at one point in time. May be around 2 decades back. But engineering has gotten very lucrative due to the IT boom, overall growth in economy and general demand for engineers in a high growth environment.
Also engineering has a lower barrier to entry and pays better than what many physicians make these days. To make anything decent as a doctor you have to do your MD, which is expensive both in terms of investment of time and money. And even after that, the job at the hospital won't pay you anything close to what your average engineer at a MNC would get paid.
And then don't forget the fact that many engineers can make money through side projects, freelancing and take adhoc risks like doing start ups which isn't even an option to most doctors.
Pinch of salt, don't be fooled into thinking there are no doctors out to make money, etc. A 5000 Rupee tip is humongous. It's probably what she makes every month. If you had offered Rs 500 instead, she'd have likely taken it happily.
Essential drugs are cheap because of not paying for R+D, plus government subsidies.
Not sure I'd agree there. In the west, even mundane drugs that don't need all that R&D, like common painkillers, antibiotics, vitamins, etc. are expensive. I think the issue in the west stems from regulations that make it difficult for new players to penetrate the market, even for generics. Running a cartel becomes easier that way.
Compare [1] and [2].
[1] http://www.walgreens.com/store/c/tylenol/ID=957-brand
[2] http://www.medindia.net/drug-price/acetaminophen/crocin-500m...
Also, the term I should have used was "Life saving drugs". An example would be Sorbitrate (http://www.everydayhealth.com/drugs/sorbitrate). Crocin is not something that falls in that category in India.
[1] http://www.goodrx.com/isosorbide-dinitrate
[2] http://medlineindia.com/cardiovascular/isosorbide_dinitrate....
In case you were telling me the price because you thought I disagreed that it's cheaper in India, I don't. My point was R&D cost is not the reason why common drugs are cheaper.
So its the currency conversion factor is what makes it look low.
It seems that every few years a new building is added, and each one is bigger than the last. Something about the pattern felt vaguely familiar. What I asked myself also exhibits unrestrained exponential growth like the pattern of construction that I saw - then I realized the answer. A tumor!
It's especially apropos when you realize that many US states have massive gluts in hospital beds and more and more procedures that once required hospitalization are now outpatient, and private insurance makes it punitive in most cases to stay in a hospital for any length of time.
The money for these building binges is mostly from Medicare, which still allows hospitalization in more cases. The fact hospitals have sufficient funds to constantly build massive facilities is a signal that they are making too much money on Medicare. Particularly disturbing when you consider that Medicare is effectively a price floor for medical services.
I've had most of my medical care over the last few years done in India. This includes LASIK (34k per eye), a selective nerve root blocker injection (8k) and a micro lumbar discectomy (85k). I expect to have a second discectomy done in the next month (being really tall sucks), provided my condition doesn't worsen and I'm able to fly.
Overall, my experience with India's medical system has been fantastic. I've found clean hospitals (not all of them!), total price was all completely transparent (+/- 10% of quoted price), and the doctors have generally been as good as in the US.
Overall, for anyone needing significant medical work done, I strongly recommend medical tourism.
Also, while you are there, have a custom suit made (particularly if you are really tall, and ordinary clothes don't fit). But be warned - I spent more on my suit than on the root blocker injection.
[edit: numbers in INR. Quick reference: 1 lac INR = 1600 USD. In spite of a few years worth of inflation, I don't expect to spend more than 2k USD on back surgery.]
[edit 2: 1 lac = 100,000.]
For lawsuit-related reasons, I'd avoid doing such a startup myself. The US is lawsuit happy - a purely India-based operation would have a competitive advantage over me.
Of course, I think this is an idea that Indian based startups can pursue.
43k INR = US$558
8k INR = US$131
85k INR = $1397
(per xe.net)
So you can get full Lasik for ~$50USD?
(See also, "crore" http://en.wikipedia.org/wiki/Crore)
https://www.google.com/search?q=34000+inr+in+usd
=~ $600 US
Total cost for this procedure was zero. I did not have to deal the insurance at all, the UniKlinik handled all the paperwork.
We were considering having the same operation in Australia prior to relocating to Germany. It would have cost at least $2500 and months of waiting.
US has achieved the rare distinction of screwing up both the parties in case of healthcare.
Indian government in reality has even more laws and nonsense but it is too incompetent to implement any of those laws. This mostly leaves the things in a Laissez-faire situation. Like it happens in any Laissez-faire situation the third parties see too many problems but the people who are actually affected are more than happy because they are a better judge of their situation.
In my village in India, we have only 1 doctor. This doctor is a homeopathic doctor who even today charges Rs 10 ( $0.16) per visit. He spends less than 5 minutes per patient and his treatment is allopathic. He moved from a distant city to this village purely because homeopathic doctor giving allopathic medicine is illegal.
Over last 30 odd years not only he has got rich but he is the most powerful person in the village. He is very good at his job, has saved countless lives, delivered babies, removed aching teeth and written countless death certificates. Yes, there have been cases of wrong diagnosis and side-effects too but overall he has lead to net positive benefit to the society in my village and hence is revered.
Many proper doctors tried to setup their shop in my village and have failed purely because this doctor turned out to be better than them.
In India, Indian Medical Council controls the total number of doctors in the country but for a bribe of around $2M you can easily get a license to start a medical school. Medical Schools make insane amount of money and thousands of poor people enter the hospital everyday where you can get away making mistakes because the choice before these poor people is "either get this treatment or die in your home".
Indian doctors in average private hospitals are far more competent than average American doctors.
It is good that American government is protecting jobs of American Doctors at the expense of public health by barring entry to Indian doctors. We Indians get cheaper and better healthcare. :P
Disclaimer: I worked for a large Cancer hospital in India.
We were denied treatment by our insurance because of pre-existing conditions. Thankfully, Obamacare fixed it and we began to receive healthcare in 2014.
The prices of healthcare are artificially inflated so high so that it is not affordable for most Americans, so they can be forced into the bizarre health insurance system. This system only makes healthcare even more expensive due to administrative costs and make it complicated for everyone. There should be no place for a middleman in healthcare.
I recently went to see a doctor for a non-serious problem, and here is how it worked out.
Steps to get medical care in US:
1) Call a specialist's office for appointment, and you will usually get a wait list of 3 to 6 months.
2) After months of wait, you get to see the doctor who will diagnose you.
3) Doctor sends in your prescription to your mail order pharmacy.
4) Pharmacy messes up your order; it could be incorrect dosage, pre-authorization, incorrect billing etc.
5) Your medication is delivered to you after few days, sometimes it can even take weeks.
6) You get bills, which could be 10x higher than what you were expecting. Your insurance company provides no explanation of the mysterious charges.
Costs: $50 co-pay, $450 for prescription.
Insurance claims: $700 specialist, $2750 prescription.
Here's how it works in India:
1) Call into doctor's office, you will usually get appointment for same day or next day. You can even walk in without appointment.
2) The doctor diagnoses you, and write a prescription.
3) You take that prescription to any pharmacy, and buy the medications.
Costs: $10 to $20 fee for specialist, and $20 for prescription.
No Insurance required
Edit: I've compared prices of various medications in US and India. Most of the medications in US cost 10x to 20x more than India.
1) Call doctor or drop by an evening clinic to see the on call doctor (who could be your doctor)
2) Doctor diagnoses you, write prescription
3) The pharmacy is usually in the same building
All that is free except the prescription that's what gets you here if you don't have private insurance but universal pharmacare is supposedly something the government is considering.
And specialists are hard to contact since you have to be referred to them by your family doctor if you have a family doctor. My last doctor who passed away had 7,000 patients he cared for he'd have to see three or four people every hour every day.
In the past year I have seen both a dermatologist and an orthopedist for the first time. I never had to wait more than a week.
> 3) Doctor sends in your prescription to your mail order pharmacy.
Mine have always gone to the local pharmacy of my choice. Same for my wife.
> 5) You get bills, which could be 10x higher than what you were expecting. Your insurance company provides no explanation of the mysterious charges.
I rarely get bills after the fact, but they always itemize and explain the charges. I also get statements showing what my insurance company paid.
Appointment times vary by type of specialist, location and luck. I've never got any specialist's appointment before a month here in New York.
> Mine have always gone to the local pharmacy of my choice. Same for my wife.
I tried sending the prescription to local CVS pharmacy. CVS said that my insurance only approved medication for 1 month, while my prescription was for 3 months. Moreover, they were charging me 4x copay than the mail-order pharmacy that works with my insurance company. I guess this is another tactic of my insurance company to maximize their profit by forcing us to buy medication from their partner pharmacy.
> I rarely get bills after the fact, but they always itemize and explain the charges. I also get statements showing what my insurance company paid.
My Insurance company's partner pharmacy keeps charging me random amounts for same mediation. I've been getting few medications for $37 each since past 6 months, but now they suddenly starting charging me $185 each for the same medications without any explanation. I could buy the same medications in India for less than $10 each.
Is there (holding the jingoistic flag wavers aside) any real disagreement on the conclusion that the US healthcare system is terrible for the average user - such that we need continual reminder?
Didn't the whole ACA debate prove that yes, we get it it's broken and there is major popular support for changes, even if the actual changes made were not themselves popular by a plurality?
This is comparable to the discussion we have here in Mexico about Oil, which is also a very touchy issue because culturally, in Mexico we have always been taught that Mexico´s oil is Mexicans property, and that any attempt to privatize some of its processes would mean to "sell the Fatherland/country" to evil transnational companies. Thus, given this premise, it is almost impossible to have a "grown up" discussion about how to fix the problems related to energy.
There is little agreement on how to change it. Most proposed changes are "let's gore the other side's ox."
That's because, generally speaking, the more collectivist proposals rely on evidence from the many, many countries that pay less for healthcare per-capita and get better outcomes, while the side that feels a more lassaiz-faire approach are relying on an essentialy religious position.
And after all, why should they care to learn the facts? All they need is enough buzzwords to call the other side stupid on message boards, and they are perfectly happy.
I'm sick to death of not being able to go to hospital here in the US, even with insurance, because what with the co-pays and deductibles, it costs a fortune. I just don't go, and I am in need of surgery that I cannot afford.
QUESTION:
Would an Indian facility in India treat me for a relatively small amount of money? Even after the flights, it would still be cheaper than the $22k I've been quoted here by multiple sources.
I think you mean how evil semi-socialized, heavily regulated medicine really is. India's medical system is as close to free market health care as I've ever encountered.
You walk into a hospital, ask the price, pay it. If you don't like the price, you can go to a different hospital and ask them. If you have insurance, you send them the bill afterwards. That's basically it, and most hospitals are for-profit. In my experience, the government hospitals are significantly dirtier than the private ones. Employer sponsored health insurance isn't a big thing. Doctors who won't talk to you without insurance [1] are more or less nonexistent.
Most likely an Indian facility can treat you. The cost is unlikely to be more than 1 or 2 lac (e.g. $3k tops), depending on your condition. Throw in another $1k for the flight + $1k for a decent hotel. If you want to learn more, send me an email.
[1] In the US I'm willing to pay cash for care before treatment, but most doctors won't talk to me. I'm told it attracts undesired regulatory attention.
Medicaid and Obamacare are the socialization aspects, which try to work within the Corporatist solution... we should have and should just tear the whole system apart.
Too many good minds work in billing and adminstrative research and development, not in medical development.
Disclaimer: I make medical billing and administrative software. I have a job because of a broken system... I'd sacrifice my comfort for a better system.
And this isn't even getting into all the ways regulations micromanage doctors and other parts of the system. Not to mention micromanage financial services - India actually has innovation in that space.
Any theories which claim that for-profit systems are horrible need to be tested against the Indian system. It's mostly for-profit, free market, etc - all the incorrect claims people make about the US are pretty much true there.
That is kind of what insurance is for though - to level out the cost for everyone.
It's a common misconception that smokers cost society. The truth is, smokers die earlier and cost tax payers less in insurance benefits and health care than non-smokers. [1] We should be encouraging people to smoke if we want to save money. (I'm joking!)
[1] http://www.plosmedicine.org/article/info:doi/10.1371/journal...
No, the point of insurance is to reduce the variance of an individual's future cost. Due to the law of large numbers, averaging across independent identically distributed people is equivalent to averaging over the future, but that's a side effect.
Averaging over independent non-identically distributed people is NOT part of insurance at all - that's what I'm describing as "the socialist part".
An example illustrating the difference - say you have 10 dice, and if a die rolls a 6 it costs $1,000. You also have 10 coins, and if the coin comes up heads, it costs $1,000. Insurance is when you charge the dice $166 and the coins $500. Socialism is when you charge everyone $333 - that's redistribution from the dice to the coins.
The link about smoking costs is interesting, however that applies at the level of government paying for lifetime costs. Annual costs are higher. So insurance for this year should cost the smoker more than the healthy person.
1. There are two kinds of health care systems in the world.
2. The first kind is private-run, profit-driven and super-expensive, the second kind is government-run and much cheaper.
3. America has the first kind. Every other country has the second kind.
You can see that story being repeated all over this page.
And replace it with what? I left Canada because of the abuse of their healthcare system, so please, share with me a model that isn't like Canada's that you'd want to move to?
Many doctors tend to show off expertise that they do not really have. I have a dead family member to show for as an instance of doctors who are too too stupid to understand what the reports were screaming at them. My family member did get top-quality care after an emergency incident put them under the purview of a different department: the department that the initial report had already made blatantly clear. And this was at one of the best hospitals in Bangalore. I have chronic health issues, myself. I had to "shop around" until I found a doctor who was (1) aware of the current recommended treatment procedures and (2) not making grandiose claims about the success of my treatment options.
And yes, medicine here is quite wonderfully capitalistic. Most drugs are very cheap, and the penurious get "BPL cards". That's enough for most people. However, things aren't all that rosy for people with weird chronic diseases, or diseases that need the latest in therapy... like cancers, etc.
> You walk into a hospital, ask the price, pay it. If you don't like the price, you can go to a different hospital and ask them. If you have insurance, you send them the bill afterwards.
Yeah, it looks great from the perspective of rich people like yourself. It's not so great from the perspective of many of India's poor people, especially in rural areas, who cannot afford the market rate.
Poverty is an orthogonal problem.
Any sources for that? As far as I have seen, admittedly, a fraction of the massive population, cost of healthcare is not the issue. Some of my doctors charged me rather high amounts and explained that they use it to offset the cost of treating poor people for free. Drugs are extremely cheap, and many docs give it away to the poor. India has problems with access, sanitation, hygiene, and education. As far as I have seen, "cannot afford the market rate" is not a common issue.
That is why in India people save money because the parents tell them from childhood that hospitalizations / accidents can cost a lot of money so better save up in case you get sick.
As for saving, people in the US don't save. And they refuse to spend money on medicine - I know a woman who easily spends $10-20k/year on entertainment, but balked at spending $8k to repair her knee.
If people can afford it, they would never step into a gov't run hospital in Vietnam.
I don't think you understand what "order of magnitude" means. You pay more than your gross salary for health insurance? If 10% is "orders of magnitude less", then you must pay at least 100%.
Also, I don't know where you are buying insurance from, but I can get insurance for about 4% of my gross salary.
Uh, that 4% is if I was self-employed. I pay $35/month through my employer.
> I tried to fall back on something from the ACA Web site, but because my employer offers insurance, I don't qualify for the better rates. Stupid rules.
The price I can get insurance for through the ACA website is the same as the unsubsidized cost of what I get through my employer. I suspect that is because we are a small company that is not getting a break from Blue Cross. I honestly don't know if I am benefitting from being in Texas, but I can buy a gold plan for $350/month.
To my knowledge, most doctors are trying to actively reduce healthcare costs on the end user. They don't see much of the profit, that just lines the coffers of the billion dollar for profit hospitals out there.
The answer tends to be "a little bit of everything." And it's really hard to cram down the costs on someone who is already making a certain amount of money.
The costs you mentioned are the primary ones, but doctors salaries are a major contributor as well.
Watch them come to work, note the care they drive. Follow them home, note the house they live in. I've yet to see a dr in the US come to work in a civic, or live in a modest house...
When I worked on an ambulance, I'd be at the hospital several times a day - in the ER doctor lot, a sampling of the cars:
- multiple Tesla S's - 3 Porsche Cayenne - 2 Audi S5s - several Escalades
Whilst there are two sides to the story, let's not pretend that doctors live hopeless lives, saddled with a lifetime of crippling student loan debt, barely able to keep their heads above water to selflessly help people.
There is a medical group in Kansas/Indiana, I think, that was trialling the novel idea of "fixed price surgery"... looking at right on $100K for cardiac bypass.
Me? To look at my explanation of benefits, the billing for my kidney stone last year peaked at over $60K.
A fair calculation of salary is some evaluation of (years of training required * intrinsic skill required * benefit to society). If you accept that, then doctors are surely near the top.
The American system is the one that is highly regulated and semi-socialized.
The Indian system is free to innovate as any start up can innovate. That is why American doctors are stunned when they go to a private Indian hospital and see the amount of digitization and high tech involved in Indian care.
You should watch this so you become enlightened as to how entrepreneurs in India are reducing the cost of health care, but still getting world class outcomes:
https://www.ted.com/talks/thulasiraj_ravilla_how_low_cost_ey...
There are no for-profit hospitals in India? From what I've seen from a quick google search, all the best ones are private, for-profit.
Of course there are for-profit hospitals in India. All the private ones are. Its just that the system has not deteriorated so much as the US, that price of basic care has shot up so much.
The procedure described in the article is reasonably simple. I am not a doctor; the reason I know is my dad had the same procedure, once in 2005 and once in 2013.
Once the procedure was done, his doctor had a post-surgery chat with my mom and me, and gave us the box the stent came in. The cost of the Stent was approx Rs 150000. The whole cost was about 200,000 (including preliminary testing, doctor's fees, stay, surgery, post-surgery, and a ride home). We did it at one of the top hospitals in India (http://www.madrasmedicalmission.org/), and talking to some folks there, I was told that the profit was made in the cost of the Stent. Even though the box quoted Rs 150000, the hospital acquired it at 1/10th that price directly from the manufacturer (Abbott).
Pay for which workers? More than Physicians are involved.
I would say that the average billing clerk in the US and the average nurse in the US and even the person who runs the mechanical systems and drive the emergency vehicles as well as any supplies (if they are sourced locally) are much much much cheaper in India than in the US.
Separately in the US I know of Indian doctors who could practice in India but fail to do so. And they have even pointed out how much "help" they could have (they actually called them "servants") if they lived over in India. Labor is much cheaper in India. This may not account for all of the price differential but running a Hospital in the US is almost certainly way more expensive than in India.
The US spends a much greater proportion of GDP[1] on healthcare compared to many other industrialised nations, and the outcomes are broadly the same as those who spend far less.
[1] http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?order=wba...
http://www.bbc.co.uk/news/health-10837726
While there are some good ideas the ruthless efficiency is a bit scary.
You probably have less contagious people around; you're going to have staff that is familiar with the various complications available all the time; and you can probably negotiate better prices based on volume for the various tools and disposables; it just makes good sense.
Is there something inherent about health care that prevents an industrial philosophy towards production?
To be fair, I can share an appalling story of how Canadian healthcare abused my son for more than a year, and how it wasn't until we started making plans to move to the US that we saw much better care (in the US).
To this day, I still can't share this without getting really angry at all they did, or didn't do.
I have my own story about how shitty the US health care/insurance system is, but I've told it before.
I'm based in India and you haven't described your condition, but I can tell you that yes world-class healthcare is available in India and compared to US at relatively affordable prices. I would like to help you out to arrive at an objective decision.
There's no contact # or email in your profile so I can't reach you.
You are blaming the wrong person.
He came back to the US and then told the insurance company what had happened. (He didn't know he had to inform the company when it happened). They balked at paying his expenses, and came up with all sorts of excuses. Then he told them the cost: $4000. The person he was talking to told him was shocked, saying just an MRI here would have cost them more. They asked him to get an post-surgery evaluation done by his primary physician, and paid the bill no questions asked.
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However, the waiting lines for everything from a basic consultation to an actual procedure are much longer, and the standard of care seems to be lesser, so a lot of people from the middle and upper classes avoid them.
[Edit: parent comment seems to have been deleted, it mentioned the average figure for Indian per capita income, and asked whether most Indians could afford a procedure like this.]
If you cant even reliably get a quote on a procedure then there are much bigger issues at hand beside the patients charges.
So if the fundamental quality of care is the same, what explains the insane markup? Salaries? I doubt it.
Also, if they rob you it's still a great deal. Do you really care a lot whether you spend $1k or $2k on surgery?
I haggle with autowallahs on principle, not because I care about paying 30rs extra.
I’m becoming more convinced every day that the US has become a two-tier society. I (and many of my friends) have had some very lean years, earning perhaps $7-15,000 and surviving. During those times, saving even $3,000 was next to impossible, because we were already $5, $10, $20,000 in debt or more. Multiply that by 10 and it’s effectively out of reach for, I don’t know, 90% of the country. The standard deductible (which is looking like it’s going to be about $6,000 under Obamacare) will often mean the loss of a home, vehicle, or college savings, especially for chronic conditions.
Meanwhile the people who determine these rates (doctors, hospitals, medical supply companies, insurance agencies) enjoy comfortable incomes of $50, $100, $250,000 or more. I don’t think they are capable of setting rates ethically. Throw in the fact that aging people are desperate and will basically pay anything to live longer, and it’s an unavoidable conflict of interest.
I think the simplest solution to all of this (and probably the most controversial) is to decouple medical research from practice. Ban all medicine-related patents. Create low interest government matching funds for the loans provided by supply companies to dentists and other independent practitioners. Remove the regulations that prop up monopolists and rent seekers. Start reducing the administrative layer that adds so much cost but so little quality of care. Then protect doctors from frivolous lawsuits with a bond system like plumbers and electricians use for catastrophic accidents so they can perform the procedures they feel are needed instead of the ones deemed “safest” or most profitable. Go after the true medical costs, the Erin Brockovich type of coverups that cost the economy billions. And especially go after the sources of illness - radiation from burning coal, carcinogens released by fracking, a hamstrung FDA that doesn’t have the resources to test interactions between thousands of household chemicals, carcinogenic herbicides and pesticides used on genetically modified food, and so on.
I’ve heard the standard arguments about how all of this might disincentivize medical research but I don’t buy them. The system we have now rewards treatments more than cures, as evidenced by big pharma ads on TV for irritable-whatever. If we really want to start over, we need to go back to pre-Nixon, before HMOs and profit-driven care. We need to spend substantially more on medical research than we do now (rather than practice), through universities and big-data approaches where biologists and chemists can run simulations and avoid human trials. Dump the current grant system and make funding far more accessible so researching don’t spend all of their time fundraising.
If we do all of this, we may just have a shot at cracking the underlying mechanisms that cause illness, basically map every virus and bacteria, the mechanisms through which genes control proteins, how we age and repair damage, etc etc. We should be growing replacement organs by now. We should have cured chronic conditions like diabetes and arthritis years ago and gotten cures for allergies, asthma and autism for free since similar pathways are at work. Right now we are doing little to no prevention, charging just enough to keep people from going to the doctor at early stages of illness, and then charging an arm and a leg for the medical equivalent of disaster cleanup. It’s really quite remarkable, and sad.
> protect doctors from frivolous lawsuits with a bond system
Malpractice suits only make something like 1% of healthcare costs, and malpractice insurance is already everywhere.
> big-data approaches where biologists and chemists can run simulations and avoid human trials
We don't know enough about the human body to be able to accurately do this. Might help for initial tests (and already does, I'd imagine), but you still always need clinical trials.
This isn't measuring the right thing. Pretend that some lawyers managed to win a case locally that the "standard of care" for a shoulder injury was an MRI, even through there is no medical reason, because a bunch of doctors in one hospital did it for whatever reason.
Now all the doctors in town rapidly move to MRI'ing every shoulder injury so they don't get sued. This doesn't show up in the malpractice premium numbers.
"Standard of care" is strictly a one-way ratchet. If enough doctors in your town/county/field do something, you have to do it, too. You can have comparative results research as long as your arm showing it has no benefit (and even creates slight radiation risks) and it won't do you any good. "Standard of care" is the legal term of art, and it always increases, never decreases.
Two more pieces of evidence that lawsuits matter [1]
1. Vaccine manufacturers were going to stop making vaccines because the lawsuit risk was getting too high. (Vaccines do have risks, although minor.) The vaccine courts were set up and everyone seems pretty happy with it.
2. Hillary Clinton's health care plan from 1993 had a whole bunch of tort reform. This is not because the Clintons hated trial lawyers! But they didn't want the courts to be the ultimate arbiters of how much medical care someone should get. You would not be allowed to sue for malpractice without first going through an arbitration process.
[1] I'm not blaming everything on lawsuits. But you couldn't run an NHS-like system privately in the US.
Trials are expensive per successful drug less because individual trials cost a lot, and more because you're dividing a non-insignificant cost by a low rate of success. If simulations let you avoid 10% of unnecessary trials, that's a substantial savings.
(Which means that the pharmaceutical companies are probably already working very hard at this...)
"Then I guess I'll have to tell 'em / That I've got no cerebellum."