My adventures in medical tourism
chrisstucchio.com
chrisstucchio.com
https://twitter.com/paultoo/status/566379518261088258
The tweet: "I want to fund the 'Uber' of medical tourism Needs 5 star service, simplicity and safety Let me know if you apply - http://www.ycombinator.com/apply/"
It really has to happen. Health care in the US is just fucked, and everyone knows it.
Then again, our friends at Medigo seem to do great service in this direction so far and have just raised a series A ( https://www.crunchbase.com/organization/medigo#/entity ), the competition seems to be heating up in this space and honestly, I can't think of anything to truly "disrupt" this industry, as the margins are pretty well known, the market is reasonably mature and the order volume is very low.
And yet people still move here for the "fucked" health care because it's cheaper, better, and available unlike other countries held in high regard, such as Canada. I am one such person who was lucky enough to be able to do that, and would never return to Canada after the abusive treatment handed out by the health care "professionals."
I had to deal with it in 2010-11, and it's only gotten worse from people we talk to still dealing with it. Don't blindly think that just because you can get your broken arm fixed for cheap or no cost that it means health care is a solved problem in other countries. Coming to the US, it was 100% cheaper, available now, and better compared to anything Canada remotely offered, even looking at private services.
As for mental healthcare in particular: thanks for the insight, I know very little about how that works in other countries. Seems like an area with room for improvement just about everywhere, unfortunately. I'll definitely keep that kind of thing in mind when reading on related topics in the future.
Nobody is setting out to specifically copy the US system, because the US system is full of accidents of history like "employer-based health coverage". That's not a useful data point in general, though. The real point is that there indeed a lot of motion happening all around the world and it is not all in the direction of increasing central control, nor is it all in the direction of decreasing it.
http://www.commonwealthfund.org/publications/fund-reports/20...
Just to add some colour:
Quality: U.S. fares best on provision and receipt of preventive and patient-centered care. While there has been some improvement in recent years, lower scores on safe and coordinated care pull the overall U.S. quality score down
Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost
Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries
Equity: The U.S. ranks a clear last on measures of equity.
Healthy lives: The U.S. ranks last overall with poor scores on all three indicators
Edit: Because you decided to edit your comment. Here are some other numbers for you.
-14 days vs 2+ years: US wait time vs Canada wait time to get help for my autistic son. We had help before we arrived in the US. We had no help for autism while up in Canada.
$0/yr vs. $36,000/yr: US cost vs Canada cost for autism therapy. The $36k Canadian cost was the soonest we could get it, which was still a wait time of more than a year after the appointment (which had an additional wait time).
Canada did have more doctors complaining that we were trying to do to much for our children though. It has that going for it.
The original posts point which you quoted is that the US health system is Fd and everyone knows it. The analysis presented here supports that. The US spends a lot more per capita on healthcare with worse outcomes and less people having access to healthcare. I’m very glad your move has has worked out for you.
(UK Medical Student)
I had an injury that resulted in a spinal fusion and other surgery at 25. Total out of pocket cost for about $250k of care and full recovery was about $500. That included second opinion visits to top doctors in Boston & NYC.
If you're on limited network Obamacare with high deductibles and HMO bullshit, good luck.
None of my comments assume private insurance unless otherwise stated.
http://blog.jayparkinsonmd.com/post/134547527433/why-theres-...
Instead, the service works by matching up riders and drivers that are close together. If the problem with the described medical practice is lack of efficiency and too much time spent in travel, perhaps Uber could make a system for multiple doctors which involves less travel time so long as patients didn't require a specific provider. Also, Uber could take advantage of the fact that its drivers' time is significantly less valuable than the doctors' time and have them pick up supplies from the pharmacy so that when they pick up the doctor, all the supplies for the next appointment are already in the car and the doctor can head straight to the next appointment.
As with many things, scale matters and trying to be a solo provider of an Uber-like service is unlikely to work.
Tell us what you think!
Chris's experience is representative of what one can expect from the Indian health care system. If you are a working, middle class person, the free market health care works extremely well.
Here's another example: https://www.washingtonpost.com/business/economy/new-machine-...
"Anesthesiologists tried to stop Sedasys.
They lobbied against it for years, arguing no machine could possibly replicate their skills or handle an emergency if something went wrong. Putting someone to sleep is an art, they said. Too little sedation, and the patient feels pain. Too much, and the patient dies. Anesthesiology requires four years of training after medical school, meaning careers might not launch until the doctors are in their 30s. It’s one reason the profession’s median salary is $277,000 a year, according to research firm Payscale."
What about the increase in physicians assistants and nurse practitioners, who seem to be taking over in the scene of less serious, more routine healthcare?
On the other hand, wages in IT suffer from an overabundance of indentured H1-B labourers, held on the very short leash of the US immigration system. This should demonstrate the importance of union representation, even at the high end of the qualification scale.
[1]https://en.wikipedia.org/wiki/Resource-based_relative_value_...
As far as overbuilding hospitals goes, you'd think that physicians and administrators will try to fill those beds at any cost, cost that is billed to patients and the taxpayer. Hospital overcapacity is not like airline overcapacity.
The AMA is a common scapegoat, except that the AMA has literally nothing to do with the number of of doctors supply-side.
You're probably thinking of the AAMC, which has nothing to do with the AMA, and is responsible for the number of medical students who graduate each year from the US. Except the AAMC has very deliberately and openly increased the number of medical student slots each year for over a decade, specifically with this goal in mind.
But even this is a moot point, because the number of people gradating with MDs is not the bottleneck - the problem is that doctors can't practice medicine until they complete a residency program. We graduate more medical students every year than we have residency slots available, so increasing the number of graduates even further will have no effect.
Increasing the number of residency slots is up to Medicare, because Medicare funds residency programs nationwide.
In 2015 there were 41,000+ applicants for ~30,000 residency positions[0]. I don't have the 2015 numbers for medical schools, but in 2014, there were 18,000 graduates in the US[1].
Increasing the number of medical school graduates in the US would mean that a larger percentage of residency slots are taken by people who went to school in the US but not the total number of residents. Ironically, this would actually be a bad thing cost-wise, since foreign medical schools are usually cheaper and students carry a lower debt load[2].
> Does this mean there is an ever-growing population of "post-doc" physicians, stuck in labs or other non-patient-facing situations?
Yes. You are likely to see them take jobs in industry - e.g. at a pharmaceutical or insurance company, but on the business side, since they're not licensed to practice. (Nor are they even qualified - medical school teaches essential knowledge for doctors, but they receive basically no training on actual clinical practice. All of that happens during residency).
It's worth noting that not all doctors want to practice medicine - for example, people in an MD/PhD program often go into research, and that's a good thing. But if we're talking about increasing the supply of practicing physicians, increasing the number of medical school applicants in the US makes literally zero difference.
[0] http://www.nrmp.org/press-release-2015-residency-match-large...
[1] https://www.aamc.org/download/321532/data/factstable27-2.pdf
[2] These aren't necessarily "foreign" students either; it's quite common for people in the US to go to medical school in the Caribbean and then come back for their residency.
What if the Gates Foundation decided it wanted to fund 1 residency position? Is there some structural roadblock in the way of its money?
But besides that, the Gates Foundation has decided that the most effective way to spend its money, dollar-for-dollar, is on efforts like polio eradication and malaria research. You'd have to convince them that this would be the most worthwhile use of their money - and quite frankly, if I were in their shoes, I wouldn't. Even if lowering the costs of healthcare in the US were their explicit goal (it's not), it would be a rather inefficient way to go about it. And eradicating infectious diseases that largely affect the poor is a much bigger win for humanity than an ongoing subsidy[0] for medical care in the developed world.
[0] This would require perpetual funding for it to be effective; as soon as they decided to stop funding residency programs, we'd go back to the status quo.
No, it isn't. Congress limited the number of residency slots Medicare could underwrite, but medical residency is not controlled by Medicare. Additionally, Medicare only pays for about 25% to the total costs incurred by residency programs.
In fact, the law that created Medicare specifically stated it was to subsidize residencies “until the community undertakes to bear such education costs in some other way.” Understandably, no one has stepped up to replace the federal government gravy train. Since the AAMC is predominantly responsible for Graduate Medical Education (the formal name of residency) it is absolutely the appropriate scapegoat for the residency bottleneck (since their only answer is to make the FGGT bigger), as is the AMA for pushing increasingly long residency requirements for medical licensure.
It seems like you don't want Medicare to be responsible for the funding of residency programs, and you'll get no disagreement from me on that point. In an ideal world, this would not come Medicare, because Medicare is the least efficient funding source for - well, pretty much anything.
But the fact remains that residency programs are not a profit center for hospitals, and hospitals cannot absorb an extra $9.8 billion/year just to train residents. And there's no other funding source for these programs at most hospitals that doesn't ultimately make its way back to the patient in some form.
It's also worth mentioning that the Balanced Budget Act capped Medicare's funding for residency programs specifically to reduce the number of residency slots available and avoid an "oversupply" of doctors. It's not that the AAMC is looking for free money so that they can keep the number of physicians artificially low, as you're implying; the external funding is what drove the increase in the number of physicians in the first place.
If you want residency programs to be funded by someone other than Medicare, that's fine, but just realize that the free-market would reach equilibrium at even fewer residency slots than we have today.
Contrast that to a completely mediocre web dev who can pull 100k+ at 21 putting in 40-50 hours a week and do you really still think physicians are overpaid? Keep in mind the majority end up in family or internal medicine working 60+ hours a week for ~$175k/yr. Going to medical school is a massive financial risk with an incredibly uncertain future.
If you want a human punching bag then turn your gaze towards hospital administrators, pharmaceutical executives, and exploitative vendors. The actual hospital employees are just as much victims of the healthcare shit show as members of the public are.
My more subtle point is that when we are discussing an existing free-market based medical system, you can not just trot out all the standard arguments about why the US should not go free market, because they are all based on a discussion of a change in how we structure the system. Here we (appear to) have a free-market system, so, one must validate all the slurs actually apply before just flinging them at the existing system.
If free-market health is so guaranteed to be so utterly disastrous, instead of flinging quasi-racist slurs at the Indians, why don't you actually go find the guaranteed-disasters in progress? Ought to be pretty easy if it's even one-tenth as bad as everyone always claims in the US context.
(Though I'll warn you in advance I'm going to account for the situation on the ground; if the doctor's office in a far-flung village with a per-capita income of 50$/year isn't up to US standards, I'm not going to award you many points. India is not a wealthy country. Only the major medical centers are really that interesting. It's also generally invalid to complain about a government not providing services when they simply do not have the wherewithal to be providing them to everybody yet.)
Cheaper to Americans. Not cheaper to it's own people. Most of it's own people are still priced out of that market.
This is not some failing of the medical system, it's just a failing of India to be a wealthy developed nation.
I think 50% of the population engaging in open defecation is even higher than San Fransisco.
It's a broken system and there's no excuse for it, but at least in the US it is not because they're being intentionally obtuse.
Now some of that is that if a complication occurs, there will be additional cost, but I was just asking for a baseline, and all they could give me were guesses.
Depending on the arrangement with the insurer, and what the recovery period was like for that type of operation, nobody in the office probably had any idea (and I bet their guesses were pretty far apart, too). Some medication used in recovery is very expensive and can add five-figure variances if someone doesn't respond well to the procedure or is in an abnormal amount of pain. And as you mentioned any complications can double the cost in an instant.
From the insurer side, they will decide after they receive the care provider's bill what they're covering and for how much. They may decide she only need five hydrocodone, not eight, so there's (3 * $n) out of your pocket (I am not googling the cost of hydrocodone at work :)). What's more is this "justification" is rarely given to the care providers. The insurer is billed $50,000, they pay $47,000 and that's that. The cynic in me wants to say it's so they don't actually have to justify partial payment, but who knows.
I've always thought we should build a massive audio archive of people calling for a medical quote and getting the runaround. I know I'd have my phone on record if I ever had to start calling. I live in a one-party consent state, and I'd use that to the max to embarrass these institutions, and have a public record of this bullshit. Shine that bright light of viral media onto the soft underbelly of the US healthcare system.
The insurers all negotiate discount percentages, pecking order for discounts, exclusions, concessions from doctors, etc.
No human understands it.
You can. Routine, profitable procedures are not hard to arrange in the US. I have personally worked in a clinic where the exact experience described in this post happens every day.
>If you are a working, middle class person, the free market health care works extremely well.
It's pretty easy in most places in the world to get people to do something that makes them money, like the discectomy discussed here.
Managing a system where the poor and the unlucky get care is a little tougher. The US does it lousily, but so does most of the rest of the world. India doesn't do it at all.
edit:copy error
For the majority, this is simply not the case. I'm sure there are exceptions as our country is very large, but most people's experience would be very similar to the OPs. I'd suggest reading Healing of America by T.R. Reed if you're interested in the working of US compared to other systems.
This happened to most of the people that I know that needed some kind of quote from the hospital. The clinic you have worked was an exception.
Yeah, lady, that includes not giving you all our money without asking how much you'll be taking.
Rather than a one-size-fits-all approach to healthcare through single payer or other subsidies, my fondest wish for government intervention would be for laws that force doctors and hospitals to provide price and likely outcome information to the general public. Give healthcare consumers the data they need to make informed decisions and the ensuing competition could drive down prices while improving outcomes.
And if you're not?
A $112,000 error happens in the U.S. but is rare. Typically the type of surgery he mentions costs between $20,000-$50,000. Or 50-100% of a the U.S. gdp per capita. This is smaller than in India where the cost of his surgery was 130% of the Indian gdp per capita.
And the issues with rounding errors has to do with the large amount of health insurance in the U.S. not necessarily free market vs. regulation. When the majority of consumption in a market is driven by enterprise customers, the pricing can become strange and very unfriendly to individuals.
[0]https://pricinghealthcare.com/prices/IowaCityASC/spine-back [1]http://www.backsurgerycost.com/how-much-does-a-discectomy-co...
The only prices I know are the price at the place I went (one of the top facilities in the region) and a few nearby hospitals. Several were significantly cheaper and if I earned in INR I'd probably have gone to one of them. But I figured that given how much I enjoy walking, why not just spend $700 more to go to the best guy?
For a kidney stone. I had to have two surgical procedures, admittedly - they went in to remove the stone, found long-standing infection, closed up and catheterized. A week of antibiotics later I had it shocked.
But still... $60K for a kidney stone.
So you would have stopped hemorrhaging money at $6,850, and then the insurance company would have been 100% responsible for the rest.
Notwithstanding that, it was considered a voluntary procedure, though there was no way the stone would pass (11mm x 6mm) - average ureter size is 3-5mm and I had to sit in the billing office and work out a 'financial solution' with them prior to authorizing surgery (negotiating anything while in this much pain would probably be considered close to coercion).
As an aside, I really dislike "Obamacare", as a name. The Affordable Care Act. As an aside, a survey a few years ago asked self-identified Republicans this: "Would you prefer some form of affordable care act as an alternative to Obamacare?", to which many replied in the affirmative. There's too much potential for bias.
http://www.cbsnews.com/news/on-bus-tour-obama-embraces-obama...
It's more bureaucratic than Italy, costs more, isn't appreciably better, and wastes people's time more.
What's more, even though Italy has a single payer system, there is also private care available that is quick, cheap and efficient - which it has to be, since the competition is "free" (tax funded).
The US has neither a free market, nor a good government provisioned system, but some mess that's neither fish nor fowl.
Erm, health insurance companies are essentially the opposite of a free market. They're as close you can get to government run without actually being called "government". With USG's recent push to make patronizing these behemoths mandatory, even the last little sliver of "exit" has been lost.
We talk to people all the time who don't have insurance (20-30M last time I checked), don't have dental insurance (~150M), or whose insurance comes with coverage caps as low as $1K-$2K that render insurance effectively useless for them in large operations. Most of the time, customers we talk to actually don't even get as far as the author did, because they can't afford the estimate, let alone the risk of over-shooting it. They just avoid getting treatment (and often get worse in the meantime).
The trick then is how to find a doctor you can both afford AND trust. If you'll excuse the plug, we started Emissary to solve that when a friend's mother had this problem. Our mission is to help connect people to high-quality options they can afford, regardless of where they live in the world.
Just a couple of anecdotal personal recent experiences with US healthcare.
1. Recently I witnessed the trouble my primary care physician (PCP) had to go through with insurance company to get approval to perform CT scan. I couldn't believe the 30 minutes, my PCP had to spend on the phone with the United Healthcare person. This is the doctor spending time on the phone explaining all the medical reasons for recommending CT scan and not some administrative person in doctor's office.
This is in contrast to a friend's experience whose PCP kept prescribing pain killers and other prescriptions instead of pushing insurance company for further tests for abdominal pain. The friend later was diagnosed with stage 4 cancer when showed up at ER with same symptoms.
2. While researching a local major hospital rated highly for quality of surgery, I came across the reports of quite a few cancer patients complaining about hospital quickly discharging patients after major surgery and restricting pain medication while in hospital. The claims don't make sense as hospital is rated so highly for Quality of Surgery and might be considered anecdotal. Until I found that two of the measuring criteria for Quality of Surgery was how long a patient stayed in hospital after surgery and dosage and duration of pain medication administered after the surgery. Talk about incentive misalignment. There is all the incentive for surgeon and hospital administration to discharge you quickly to maintain and improve Quality of Surgery rating.
The author of original article mentioned staying in Indian hospital for 4 nights. Do you think a US hospital will keep you 4 nights for same surgery? I seriously doubt it. You most probably will be released few hours after the surgery or at most after overnight stay. Is the quality of care becomes lower because an Indian hospital kept a patient for 4 days instead of 1 day by US hospital? What does it say about relationship between quality of surgery and all these metrics such as duration of hospital stay, pain medication dosage and duration?
I found a lot of studies which used hospital stay duration and pain medication dosage and duration while in hospital as a proxy to quality of surgery but none that showed these metrics have anything to do with quality of surgery. Also, while quality of surgery takes into consideration the pain medication dosage and duration in the hospital, it ignores the pain medication dosage and duration patient was prescribed after being released from hospital. Similarly the overall healing and recovery time required by patient after the surgery is ignored in favor of the portion of recovery time patient spent in hospital. Hopefully, you see the incentive misalignment and mis-measurements.
You will get what you measure, nothing more nothing less. It is up to you to decide whether a measurement is relevant or not to what you trying to measure. You should not only worry about what a statistical study show but also what the study doesn't show.
Hospitals are full of all kinds of hard-to-kill microorganisms. They really are not good places to stay after a major traumatic event (e.g. surgery) if you don't need the resources of the system; staying will only increase your chances of getting a life-threatening infection. When I get home from the hospital, I try to change out of my clothes as soon as possible for this very reason.
As for pain medication, well...one only needs to look at the enormous rise of opioid addiction and prescription medicine abuse in the USA to see that moderation of these very dangerous medications is in the patient's best interest.
The medical system is far from perfect, but don't operate on the assumption that the people working in the field are ignorant of the problems you're pointing out. There are many things we could be doing better, especially on the transparency and patient education side of things, but it's a huge industry and big ships turn slowly.
One of the biggest flaws with the American health care system and single payer as well is that it's removed the cost component from peoples considerations of what care they should receive. We all pay for this idiocy in the form of our skyrocketing insurance premiums. Do you really think people would want to sit in a hospital if they actually had to pay the nursing staff $1000 per day out of pocket? If they had to pay the janitor $20 for coming into the room to clean up the mess they'd made? $200 for the physician followup? Of course not.
The above poster complaining about withholding opiates and statistically backed discharge time frames is a huge part of what's wrong with health care across the developed world- not just the US.
If I could snap my fingers and magically disappear any single insurance provider, it'd be United.
For my wife's specialty (ophthalmology), they're they only insurer in our region that requires a referral from a primary care provider for a visit. So, if you have blue-cross and have trouble with your vision, you can just go see an ophthalmologist.
If you have United, you need to call your primary care provider, explain your problem over the phone or (in some cases) go in for a visit, and get them to refer you to an ophthalmologist.
It's a hassle for us, but much much more of a hassle for primary care providers who are wasting tons of time on referrals and paperwork an in effort to save United money. It's a good part of the reason that primary care providers have to have the most support-staff per physician[1], despite having relatively lower reimbursement rates.
[1] http://www.mgma.com/Libraries/Assets/Key-Findings-CostSurvey...
This was going on for several months.. Eventually we visited doctor in Athens, the whole thing was diagnosed and solved in weeks. Solution was $2 pill and routine surgery.
I really recommend to anyone with some 'mysterious' health issues to visit REAL doctors.
Edit: for extra fun, ask them what country Amsterdam is in.
Is that so?
Since a lot of people have hypochondriac tendencies, this system has the advantage of reducing the amount of people that go to hospitals, which in turn reduces both infections in hospitals and the overall costs of the system. But for individuals, the chances of getting screwed are higher.
edit: typo
I understand the desire to not spend resources on hypochondriacs, but the last time I heard that from my doctor I ended up being admitted to the intensive care unit at the hospital the next day with meningitis. According to the doctors there, I could have died if I'd waited a bit longer.
Needless to say, I don't feel as confident in our healtcare system after that.
On the bright side, the Dutch hospitals have a great track record at low multi-resistant bacteria, which are more common in other countries. One of the reasons for this might be their stricter rules of admitting people in the hospitals.
GPs in the UK (who are most certainly real doctors) refer you to specialists - state or, if you want, private. They don't co-ordinate care after that.
There are urgent care centers that are the less-crazy version of ERs, and a lot of primary care stuff can be done self pay. While I have access to insurance through my work, I vastly prefer the quality of the self pay system. You do need to do some research in advance, but there are some pretty cool innovations out there, and services you just can't get via the insurance system.
http://theselfpaypatient.com/ is a good resource.
http://www.kvue.com/story/news/investigations/defenders/2015...
For a simple chest pain, doctors here would tell you 145566 possible scenarios that may happen with your body, and wouldn't confirm any unless he sees a lab test. And then, a tide of lab tests would start, which will cripple you financially, and emotionally because all you are thinking is which test would be +ve, which -ve; diving on internet where people usually blog about their -ve experiences. Usually, it could be just a muscular pain, etc, which become so irrelevant as you are undergoing all these lab exams.
I don't want to blame the doctors here as such, because that's how they are trained here. I guess it boils down to this robust "suing infrastructure" here, that if you missed out a rare symptom with a patient, he will sue you and finish your career.
One thing which I couldn't understand is why in a developed country, lab tests are so expensive. An Xray, costs about $100; similar thing costs about Rs 80 (equivalent to $1.25). Shouldn't they be cheaper here, given there are gizmos for everything, and all electronics items are much cheaper here than India. I think these costs are all artificial.
I think a mix of both approaches (insurance + free market) would better.
Many lab tests - though not all - are effectively commoditized. There is little difference in quality, and the requisite supplies are widely available at low costs. X-rays have been used for medical purposes for literally over 100 years, and it's not very difficult to train someone to take an x-ray properly using modern equipment. (Actually interpreting the results of a test is a different matter).
For tests which fall under these categories, it will always be more expensive to obtain them in the US than in India, because the cost-of-living in the US is much higher, and paying people to actually perform the tests dominates the costs of the test itself.
There's a little more to it than that, but that's the general idea.
Out of pocket price of standard blood panel lab in the USA with a follow up phone call if something is wrong, with insurance: $1500. There is no ability to estimate even vaguely what the price will be beforehand, and the bill may take a month to arrive in the mail. Your insurance agency will fight you at every turn for all but the most mundane routine procedures. There will be a billing error somewhere, and it will be to your detriment. They may refer you to collections if you do not pay the incorrect amount while disputing the charges, as happened to my girlfriend. Face time with the doctor is probably minimal, and you will be stressed by the doctor's attempts to hurry you out the door and probably forget to ask important questions.
Out of pocket price of extended blood panel lab plus two hours of doctor face to face analysis without insurance in Argentina: $50 USD, and the doctor will speak perfect English. Smartly, the doctor arranges the items on the blood panel before you visit him in the first place. No in-depth discussion of your health can begin before the doctor cannily takes your medical history via a very casual schmooze-sesh which plays out more like old friends catching up. You leave the office relaxed, understanding your health action-items.
Where do you think I'm going to go when I need serious treatment? The US medical system is a failure and an international joke.
Yep. Can confirm: US hospitals and other care providers are total d-bags when it comes to billing. It doesn't help that for anything remotely complicated you end up receiving 2-3 different bills from each of 5-6 different entities (the hospital, a couple of doctors or departments in the hospital, a couple of labs, a GP for your checkups afterward, et c.), only one of which from each will actually be the one you need to pay. It can easily take most of a year to sort all the crap out, especially if you have any kind of dispute with insurance or billing error from the providers (the bigger the procedure, the closer the probability of this approaches 100%). Makes for a totally stress-free recovery. eye roll
It's like it's designed to screw up people's credit, even when they're trying to pay what they owe.
> It's like it's designed to screw up people's credit, even when they're trying to pay what they owe.
I had a bill that was 100% covered by insurance, only they never sent it to me. it's 3 years later and despite my insurance now paying the bill twice, countless conversations, some collections agency is still giving me calls, and it's still on my credit report.
I have insurance, I make a great income, I paid every bill that I received. Somehow it's still biting me.
(It's not a huge debt, and I disputed it as soon as the collection notice arrived, and my credit is not direly affected)
UK: 8.8% of GDP total spending, of which 83.3% public = 7.33%. http://www.ons.gov.uk/ons/rel/psa/expenditure-on-healthcare-...
US: 15.2% of GDP total spending of which 48% ($3,426/$7,146 per capita) public = 7.28% https://en.wikipedia.org/wiki/Health_care_in_the_United_Stat...
Edit: The 2014 figures are even worse. 17.5% of GDP total spending of which 28% federal and 17% state and local = 7.88% of GDP public expenditure. https://www.cms.gov/research-statistics-data-and-systems/sta...
"This has led many households to incur Catastrophic Health Expenditure (CHE) which can be defined as health expenditure that threats a household's capacity to maintain a basic standard of living.[2] As per a study, over 35% of poor Indian households incur CHE which reflects the detrimental state in which Indian health care system is at the moment"
https://en.wikipedia.org/wiki/Healthcare_in_India
In fact, if anything, that perhaps reminds me of the pre-NHS UK healthcare system - which Aneurin Bevan, the founder of the NHS, clearly referenced in the title of his book "In Place of Fear".
https://en.wikipedia.org/wiki/Aneurin_Bevan
Also interesting to note that, according to that first Wikipedia article, India appears to be considering a universal health care system.
The infant mortality rate in India was 38 per 1,000 in 2015. That's really not good.
What's also interesting, is that the US is likely a large net 'exporter' of medical tourism. I currently work with hospitals that are rapidly developing large businesses in medical tourism, because for all our needless systemic problems, people trust that, if you have the cash, you can find a good doctor.
When you are applying "Free market principles", you go to the place that maximizes your enjoyment/treatment per $$ spent.
Infant mortality in Kerala is 6.7 (6.2 in US), life expectancy at birth is 76 (78.7 in US).
Per-capita income in Kerala is $2,271 ($53,000 in US)
So yes, you can provide good healthcare even with not a lot of money floating around.
References: https://en.wikipedia.org/wiki/Kerala_model
Ambulance ride, first surgery. Helicopter ride, second surgery, a month in hospital and third surgery and then another month or so in hospital to ween him off the morphine he had become addicted to, and to get walking again.
Of course, there was never a bill.
All 10 people spent at least an hour talking about health insurance, "Doughnut holes", the VA, and lots of other things related to the abysmal health system in the US.
It occurred to me I've never heard such a conversation in Australia, but it's simply automatically part of life that you get good care.
The more you think about it, the more crazy it seems on multiple levels.
Edit, typed < instead of >.
When I got to Medellin, my dentist did not want to do the inlay, said it was too invasive and that he would rather fill it.
It cost less to fly to Medellin, get all my work knocked out, than it would have for just the one inlay. And I absolutely believe that my Colombian dentist, who spoke English quite well, did better work than the Atlanta guy did. My teeth look better than they have in years.
I will never again have significant medical procedures done in the US.
This guy:
To find the particular dentist, I reckoned that so long as the dentist spoke English and the office was well-equipped, I'd be fine, so I did a quick search on Google for Medellin dentists, picking the one that I found had the best copy on his website. Given that few in Colombia know a lot of English, it's a good bet that the dentist would be writing the copy himself.
If I got to the office and got spooked for whatever reason, I could always just line up another dentist or just forgo getting the work done. But Dr. Mejia was great.
It's something I've sometimes wondered about before.
https://alexcabal.com/today-i-had-a-weeks-vacation-in-colomb...
One striking area you can see the difference in the US is in elective surgeries -- for example cosmetic surgeries and Lasik surgeries. Insurance doesn't cover elective, so the providers take cash only (or credit/payments). Providers often have the fanciest and newest equipment with clean modern facilities. Prices are disclosed to and agreed upon by the patient ahead of time, and in general get cheaper over time due to competition.
FYI, the Surgery Center of Oklahoma is one of the only surgery facilities in the US which actually lists their price schedule on their website: http://surgerycenterok.com
When you're dying on the side of the road, you'll pay anything to get better--and a free market will take everything, ruthlessly and without pity. That's what's happening to us, right now, today. If my mole had been cancerous, a doctor could have demanded any price to remove it, and I would have paid it, because the alternative is death. If my mole had instead been a time-sensitive situation, I wouldn't even have time to shop around, and I'd have to accept any price my doctor quotes--or chance death. The ability to shop around is typically at the crux of free-market health care arguments but shopping around isn't possible in life-or-death situations like health care.
Literally every other country in the world understands this, and that's why health care is rightly socialized in every single other country on earth except America.
Is there only one Doctor where you live?
>...The ability to shop around is typically at the crux of free-market health care arguments but shopping around isn't possible in life-or-death situations like health care.
Most of health care provided is not an emergency life or death situation. You have never had been given healthcare where your life wasn't in immediate danger? That is quite unusual.
>...Literally every other country in the world understands this, and that's why health care is rightly socialized in every single other country on earth except America.
Every other country? That is clearly false - you might want to read the article for one counter-example. (There are very few countries where all health care is socialized. Most are a mix of private and public options like the US.)
However most, if not all, doctors will absolutely charge you less if you pay cash, you just have to ask for it and have the conversation.
Everything else in your comment is true, but this line is not. Healthcare is expensive, just like cars, houses, and enterprise software, but the reason that healthcare prices are high is very specific to healthcare (there aren't any other industries that have similar models).
For starters, insurance smooths risk. It is not there to save you money. By definition, insurance will always cost more than than paying out-of-pocket in the long run[0]. Think of insurance as a luxury that mitigates (but does not eliminate!) the worst-case scenario for you. It costs more (a premium[1]) because this luxury has value to you.
The fact that this does not always apply to health insurance is a sign that health insurance isn't entirely (in the economic sense) insurance; we just happen to use that word.
> One thing I've never understood about the US system is why do the doctors charge more for paying cash e.g. $200 for a visit, whereas insurance reimburses them less than half e.g. $80.
In general, Medicare and Medicaid reimburse the least - the amount that they reimburse is actually less than COGS (not on all individual services, but in the aggregate, it amounts to 7% less)[2]. As a result, providers have to overcharge private insurers and uninsured patients in order to cover their own costs.
The price that you see on your bill is basically a starting point for negotiations. A company like Aetna will say "okay, there's no way we're paying that, but we will pay you 250% of what Medicare reimburses for the same procedure".
As an uninsured patient, you can do this as well if you know to ask. It's less of a practice for outpatient care, since that tends to cost less and also have more predictable costs associated with it, but for (e.g.) unexpectedly large bills for inpatient care, you can always just tell them "I will pay $X today in cash if you reduce the bill to that amount." They'll always be willing to do it, because they literally do not care about the money that they get from uninsured patients - the large bill is intended to be received by an insurance company, not by an individual.
[0] ie, on an infinite time horizon.
[1] The fact that your fixed monthly payment to an insurer is also called a premium is not a coincidence.
[2] To preempt the inevitable question: COGS refers to the direct costs of providing a service, so this is before even accounting for the fact that an outpatient office has to pay rent, pay its staff, etc.
I don't understand how doctors paying less to medicare/medicaid causes them to have to overcharge other customers. If they are not making money on Medicare or Medicaid patients it's my understanding they aren't forced to see them.
Sort of.
It's less the case for outpatient practices unaffiliated with any hospital network, which is why the disparity between insured cost and out-of-pocket costs for those practices tend to be smaller. But unaffiliated outpatient practices are a dying breed.
For hospitals, it's more complicated. In theory, this would be true. In practice, almost all hospitals other than the ones the VA operates do take both Medicare and Medicaid because of a confluence of other regulations that makes it unfeasible to refuse care to them. That said, despite this, the amount of money that hospitals lose on public insurance has increased to the point where a number of large hospital networks have discussed rolling back the services they offer to Medicare patients (such as outpatient care) or even cutting it off entirely.
Would you mind either explaining the regulations or pointing me at some sources that explain the regulations that bind hospitals into paying for Medicare and Medicaid? And by affiliated, does that mean has admitting rights, or is owned by the hospital network?
Sorry not trying to be argumentative just trying to learn about the convoluted world of healthcare.
This ignores the money saved from group bargaining. It is often not possible to negotiate on price as an individual. A good health insurance company will have more information on pricing than an individual would have and is in a better position to negotiate for the group.
If you don't have insurance, you just pay the chargemaster rate. Keep in mind this is negotiable.
One interesting thing about her experience was that he was told by the doctor in Thailand that he would not be able to offer a surgical facelift since he already had one 5 years earlier. It was very interesting to see doctors saying no rather than risking poor results with multiple surgeries. A person like Joan Rivers is a good example of what can happen when you have way too many surgeries.
Overall though my opinion is that for rare or esoteric conditions, there is no place on earth better than the US. However for common elective or nonelective surgeries, going abroad may not be a bad idea.
The OP is absolutely right that it would have been more difficult for me if I knew nothing whatsoever about India. However, I probably could have paid a couple of thousand USD more and OnP (the hospital I stayed at) would handle things for me. I know they have a medical tourism office, albeit catering primarily to gulf residents.
I'm not deadlifting anymore, however.
(Admittedly, I hurt it deadlifting with poor form, but fixing the form and strengthening my back with it was the single biggest contributor to getting better.) MMV, of course.
I would very strongly recommend reading that book (which will set you back a whopping $10) before undergoing any back surgery.
(I'm not a doctor, this is not medical advice, YMMV and all that. Still. If you suffer from chronic back pain, or carpal syndrome, read the book.)
I assume its something similar to Thomas Hanna's Somantics from the name and Amazon description, which would be something I would recommend people give a try before going under the knife.
Oops, forgot at include dying also.
As a starter: I'm woman with an extremely strong family history of breast cancer before age 50. Standard clinical guidelines is to start doing heavy monitoring 5-10 years before the youngest person in the family tree was affected, since usually cases get progressively younger start dates. Since one of the people was around age 32, I'm under the age of 30 and I go for mammograms, ultrasounds, and MRIs every year as if I were a cancer patient already.
Mammograms, ultrasounds, CAT Scans, MRIs, (any form of medical imaging radiography) are actually a perfect example of how the market internationally could be more efficient, but it turns out that's impossible. At its core we're basically talking about photographs, something facebook manages to serve from location a to person b that is nowhere near location a every day. Why couldn't I go to any imaging place in the US, and have my images sent to the lowest cost provider somewhere in india to be read and interpreted by a radiologist, and then have the results sent back to me. Unlike Chris, I don't even have to meet my doctor, all I have to do is send him images.
It turns out that medically this is blatantly difficult if not impossible to do. The reasons are 2 fold
1) It turns out that age and variations in how and why the machines that used, as well as technician speciality, matters a ton in image quality.
http://www.kevinmd.com/blog/2010/09/mri-places-good-quality-...
As a patient, I have no idea if the price I am being quoted is reflected of image quality or price inflation (and this is before being read)
2)Quality of the radiology report is highly dependent on the MD reading the images. This has been well studied since the early 2000s (one of the latest examples being here: http://www.ncbi.nlm.nih.gov/pubmed/23737538 ) At under the age of 50 with dense breasts, I'm significantly more likely to have imaging misread if I went into a community imaging location, even if they had top notch equipment, because the radiologists do not have enough volume of high risk cases to make sure I am not falling into false positives/recall on a regular basis - which would mean even more imaging costs.
In order to effectively export my images, I would have to find a way to duplicate part of the specialized cancer wing I go to. Cost savings actually would be minimal - I'd be running more tests, seeing more doctors, and probably have a delayed diagnosis if/when my expected inevitable happens (which means more expensive drugs, longer treatment times, ect)
And while my example is specific to me, many people have similar sorts of conditions where treatment location, equipment used, and people involved have higher initial costs but lower lifetime costs for all sorts of conditions. Pretty much any semi-serious disease falls into this category.
I'm game for better ways of paying (insurance does cover this, because as I said, lower lifetime costs to them by paying for preventive care). I experiment with things like telemedicine - I use a compounding pharmacy and Specialized RN over the internet to manage acne that refuses to go away. I'd totally go to the Caribbean for teeth whitening or LASIK.
None of these things need regular, serious followup, or run risks of painful drawn out deaths/longer painful medical care with much higher costs if done very incorrectly on a regular basis.
Medical tourism isn't the answer - understanding what these services are in relationship to risk is.