Show HN: Compare prices that US hospitals charge patients, insurance companies
turquoise.health
turquoise.health
For a few "popular" random examples that I think HN might have heard of: one branded Epi-Pen is £26.45; Naproxen (the NSAID painkiller) is £4.29 / 56 pack; and omeprazole (PPI used to treat gastric reflux) is £0.84 / 28 pack.
A more expensive example might be the cystic fibrosis "designer drugs" lumacaftor with ivacaftor -- 112 tablets are £8000 (to be prescribed by a specialist, if the patient has the genotype to respond to it -- a total annual cost of about £26k). The US equivalent is $379,780 [1].
(NB: The price you pay as a British patient is usually £0, unless you are a working-aged and working English person -- at which point it is £9.15 per item [independent of its cost] or a fixed "all you can eat" prepayment certificate that works out at about £8.83/month -- which is what I have. Oh, and plus the taxes, of course...).
[1] https://www.jmcp.org/doi/pdf/10.18553/jmcp.2018.24.10.987
I think you're mixing up a few things here. The co-pays are meant to make the patient directly pay some of the cost to decrease abuse of the system. There are many different structures for co-pays so saying anything general is kind of difficult, but there are reasonable arguments supporting such a system. In Sweden for example you do have to pay certain costs (which are capped) for essentially the same reason.
But that has nothing to do with the fact that prices vary so widely for the same products and services. Personally I think that the US system should at a minimum require that
1. All medical products' and services' costs to published publically;
2. All costs to be non-discriminatory (meaning everyone regardless of any insurance plan or none must pay the same);
3. All costs be available prior to any services provided.
In other words, there are no negotiated plans with different prices, there are no surprise bills, patients actually are able to understand costs, and real competition is actually theoretically possible. None of this would necessarily preclude an insurance plan from having co-pays, it would just make the only point of the insurance plan purely financial and open as it should be.
Of course the US could just move to a single-payer government-run system, but that's a different discussion. If the goal truly is to have a market-based system, then I think my points above should be implemented.
However, if your point is that the current system would also be improved by the tiny change of allowing medicare to negotiate prices without any of my other ideal changes, then yes I agree that would be a change for the better.
> It was approved for medical use in the United States in 2015, and in Canada in 2016.[3][5] In the United States it costs more than $US 22,000 a month as of 2018.[6][7] While its use was not recommended in the United Kingdom as of 2018,[4] pricing was agreed upon in 2019 and it is expected to be covered by November of that year.[8]
My insurance wouldn't cover it until I tried cheaper alternatives first, but I didn't want to try those given their fair more serious side effect / risk profile. Because of the manufacturer program, I was still able to get it for $25. I dont know if that would be possible in the UK if the programs arent offered there.
Also, no waiting period other than the medicine had to be shipped from a specialty pharmacy that could deal with the temperature storage and handling requirements. There is a bit of a wait to see a specialist to actually prescribe it, but that varies by geographic region and specialty.
For comparison of terminology, this is what we would call a co-pay in the US.
You pay 9.15, your health coverage pays the rest. Thus you are “co”paying.
https://healthcostinstitute.org/hcci-research/international-...
That's basically what a copay is.
Edit: By “current” I mean the Trump administration.
You as a consumer now have the ability to search, but do you have an incentive to do so? Do the savings come to you?
Some of it, perhaps. But it's likely not that much and only under some circumstances.
E.g., if you are just faced w/ a copay on a visit, your copay is going to be the same at two facilities.
Coinsurance is different - there you may realize some savings. IF you are below your deductible for the year that is also different. You may realize savings and care.
But there are a decent number of patients who for most of their visits will not see much incentive to search.
Also... it is possible for these releases to help hospitals coordinate on prices in a way which they currently do not. (Tacit collusion, not explicit, back-room, definitely-illegal collusion.)
Hospital A now knows exactly what Hospital B gets from Aetna, so Hospital A may realize it can hold out for more w/ Aetna b/c Aetna is willing to pay their competitor more for the same procedure.
Both of these questions are above all empirical questions and one to which we do not yet know the answer. I would be wary of confident predictions.
The effect. The effect will be strong.
The logic that you posit to contradict this is that for most patients "there will be no incentive to search for better prices". That seems to ignore entirely the dynamics of other established businesses like supermarkets.
Most people go to supermarkets and the vast majority are not looking for the absolute best price or even the median price. However supermarkets battle out in pricing to catch the few customers that they know are price sensitive. Its the minority rule. This is a positive externality by which everyone benefits.
This same dynamic will be observed in healthcare.
I agree in that much of it is unknown and also the time horizon is very uncertain. But the effect will be felt and it will be profound.
Or, I can go to Tennessee and get the appendectomy (MSDRG 343) for $4,700 and pay that directly.
Many people will make that choice Kaiser gets less business putting downward pressure on their pricing. And the folks in Tennessee might see they can raise their prices so that it starts to equalize to some point.
There will be several 2nd order effects, where the overall impact is unknown: 1. The transparency rule not only reveals prices to consumers, but also to other insurance companies and other hospitals. Since these price arrangements were until now secret, that will impact negotiations between payors and hospitals in competitive markets like major cities. This is likely to force outliers on both the cheap end and expensive end to bring their rates closer to market. If either hospital or the insurer cannot bring their rates closer to market, this may accelerate consolidation of hospitals to improve negotiating power, and/or cause smaller insurers to drop hospitals from their network. This may give some room to relief to small practices that were formerly in danger of losing payor "network" access; at least while the big coverage fights happen upstream between hospitals and payors.
2. the transparency list is not comprehensive. So, not all medical services are shoppable (i.e. scheduled in advance, typically non life-threatening), this may cause hospitals to shift costs to services that consumers have no control over, meaning (1) emergency and (2) unlisted procedures. It will take a few years for hospitals to understand the impact the rule has on their bottom line. The implication is that there will be a waterfall of margin pressure on scheduled procedures at independent doctors , but it will take time to happen.
I have no idea why doctors need to sacrifice their entire 22 to 30 year old lives constantly slaving away, working on call, sometimes 24 hours at a time.
Relax some of the draconian, outdated hazing rules. Attract more smart people, make it so young people can have lives and become doctors.
That might address the cost of labor. The cost of medicine on the other hand is simple, the government should be funding research into medicines and then offering it for sale at basically the cost of production. Only other way is to reform patents and whatnot, but it seems easier to just do the research with the top tier research facilities the US already has via the higher education system.
There’s probably some other issues such as tort reform and medical equipment costs that need to be address too. But I think all prices can be brought down by increasing supply.
Of course the fact that he did this after spending 3 years trying his damndest to gut our already mediocre public healthcare system makes it a bit of a eye roller, but you know, even a broken clock is right and all that.
- 'Most Favored Nation' drug pricing. Also as of 1/1, big pharma has to charge US payers the same price as the lowest price they charge to other countries. One example cited is insulin. Apparently, the price of Insulin from the same pharma is 10% the price in Canada as it is in the US. Now that this law is enacted, that pharma has to charge the same in the US as they charge in Canada.
- 'Right to Try'. Greatly reduces restrictions on terminally ill patients' access to experimental treatments.
- Removed the mandate on the affordable care act. People who do not have any health insurance were liable to pay a fine. That fine was removed.
- eHealth across state lines. Doctors were not permitted to see patients via video calls across state lines. During the pandemic, that restriction was removed.
The bill [1] was introduced by Mike Braun and others. None of which have anything to do with Trump or his "administration", these are voted governs who did this all on their own.
1 - https://www.congress.gov/bill/116th-congress/senate-bill/410...
One day I asked how much go get shot without insurance.
It was $15.
I was paying 4x to use insurance. And insurance was getting billed on top of that.
I asked how much it would be without insurance and they quoted me $350.
So if it's any comfort, I'd guess your insurance wasn't getting billed on top of that. They probably paid $15 and pocketed your copay.
Some might call this "keeping two sets of books", but apparently it's par for the course here in the glorious USA.
Up until recently [0], it was common for insurers to have rules preventing health care providers from telling you when it was cheaper to pay cash.
[0] https://www.aarp.org/health/drugs-supplements/info-2018/gag-...
Unfortunately, most of his works are in Norwegian, but his last essay before dying from cancer was called Thank you, Norway - and good luck on your watch (Google Translate uses "god vakt", but I guess it is an idiomatic greeting to guards whos shift is starting) [0] - he was afraid the three pillars of the Norwegian society was somewhat threatened: justice, trust, freedom
[0] https://translate.google.com/translate?sl=no&tl=en&u=https:/...
Anyway, it seems that there are orders of magnitude differences for the same service.
The service 'MRI Lumbar Spine With & Without Contrast Material' has a lowest price of $210 while the closest and highest I personally could find was ~$4109.
How can there be such a large difference in price for something that, I believe, is legally & medically the same procedure?
From the data we did get our hands on, I remember seeing price differences like $200 vs $4k for the exact same procedure. The low cost provider was usually a private practice radiologist in a small shopping mall type retail location who ran a very efficient, low overhead practice. They were terrible at marketing and ran discounts for volume from certain channels. They were only open Monday to Friday from 8am to 4pm, read times could often (but not always) be slow, they handled the least complex cases and no emergencies. Cash pay up front from patients resulting in no/minimal collections. The high cost provider was usually a large University affiliated medical center who ran a less efficient, high overhead radiology department but who also, in their defense, had to handle more complex cases as well as be open 24/7 to service one or multiple emergency departments with faster read times. Lots of fighting with insurance companies for eventual reimbursement. Lots of bad debt that went to collections and had to be written down.
If you pay University prices for a simple MRI you are effectively subsidizing the ED admit who needs a complex imaging procedure in the middle of the night. If consumers start to shop for MRIs the way they shop for airline tickets - which they probably should - one downstream effect will be to remove billions of dollars of "subsidies" from the most well-resourced radiology departments in the country. If I remember correctly the diagnostic imaging market was something like $150 billion/year in 2015, and probably even bigger now, i.e. plenty of potential fat to cut.
The uninsured person going to the hospital at 1AM that requires an MRI because slipped a disc in their back still ends up getting that MRI. When they fail to pay that bill, which would be 5%-10% of their annual earnings, we all still pay for it. We just decided to layer in debt collection, anxiety, and depression onto the patient in lieu of cash.
As someone who still considers themselves a fiscal conservative, and also believes we need true universal coverage for all Americans, this seems like a no brainer to me at this point (and I say that as someone who would have not supported this in the 00s but has evolved significantly on this issue).
What I think would be best though, is to eliminate medicare/medicaid, hand people cash, and get out of the way.
The high-order problem with medicine isn't coverage or insurance. It's price. There are only two ways to get price under control: meaningful competition, or government price controls (e.g. single payer). Single payer would end up like public schools: one choice for everyone, probably OK quality, but not great.
I think we could do so much more here if we just created a cash market and handed people money. It's what Singapore does. It would let doctors compete on -- even discover -- what actually matters to consumers -- wait times, when procedures take place, even how comfortable the office is. I would much rather have a market with choice and variety than one that straitjackets everyone into a one-size-fits-all system that might work for some but probably won't for others.
I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices.
It's funny. In a community where people are so focused on innovation, and startups, and choice, I see a lot of support for a national single-payer scheme. I would much rather take the collective energies of this community and apply them to innovation in this market, with meaningful choice and competition. Medicine needs more of a startup mindset. And for those roasting me about how it's different/dangerous/risky: what we have today is KILLING us, economically.
That is the #1 most effective thing that Americans can do to reduce health care costs. #2 would be to change the standard American diet and eat healthier to reduce rates of obesity and diabetes. Almost every other proposed structural change or intervention we looked at was minimal by comparison.
I hope this never happens, but let’s say you got in a motorcycle accident and need that lumbar MRI to figure out the damage. What are going to do, get back on that wrecked motorcycle with a fucked up spine and go to that 210$ place?
They do it because they can do it and get away with it.
The trouble is that emergency care isn't what drives the majority of healthcare spend. What does is actually chronic conditions: dialysis, diabetes, autoimmune disorders, chronic weight conditions.
That's what we need to worry about.
And if there was a real market here, you wouldn't need to shop around because all the people that do, would enforce some level of price discipline on the market.
Think about it. For any good sold at, say, Wal-Mart, say Gatorade, there are some people that want it a LOT, even NEED it, while others are more on the fence. There's only one price on the shelf and it's calculated to get a lot of people buying. So in effect, the people who are more indifferent (want it less) are actually doing a pretty significant service to the people who want it a lot, by guaranteeing the price will be set low for everyone.
There's no reason something like this can't apply in healthcare.
If no one publishes their prices how do you set yours? 2 dollars? 2000 dollars? 2m dollars?
Within a day or two, I received a phone call from some department at my health insurance provider telling me "Hey, we see that you are going to get an MRI; did you know that you can get the exact same procedure at providers A, B, and C, for a lot lower cost?" They did this even though the hospital's radiology department was in-network.
In this case, the cost difference was similar to what's noted here - about $4,000 vs $450. Since the insurance company was paying most of it, aside from my copay / share of cost, they were motivated to provide me a little transparency.
To be honest, as a patient, I would have preferred to get the MRI at the hospital; their facility was nicer, cleaner, more modern, and there was better data integration for getting the results to my neurosurgeon and keeping them as part of my holistic medical record. Nonetheless, I went to the cheaper provider.
Economic research confirms this. Mergers result in higher prices due to less competition.
What we need is way, way, WAY more competition in healthcare. 10x as many providers, 10x as many clinics, with prices posted on the wall. When they start losing business, they'll notice.
I honestly think that free market healthcare is doomed to failure. The information a-symmetry, the size of hospitals compared to populations, localization, the degree of specialization, strategic nature of services, and the social externalities are just too great to ever really have a market. But that's just me on my soap box.
Hopefully transparent pricing will do some good at least. I wonder if requiring insurers to share savings in cash would further encourage people to shop around (eg going to the place 4h away to get a 2k MRI instead of a 4k MRI means you get say half the saving [1k] back from your insurer)...
If this was possible, I'd agree with you. But the reality is that the best we can hope for is single payer.
It just didn't register that the AMA is the sixth-biggest spending organization on DC lobbying [1], right behind Blue Cross Blue Shield (an insurer) and the American Hospital Association.
People worry about the NRA and all kinds of other stuff. They should really get mad about how outrageously the medical industry lobbies (as do the realtors), and how much they've managed to extract from ordinary Americans. It's an utter coup of PR that people aren't rioting in the streets about this. Everything about the medical industry -- licensing, high physician salaries, etc. is rigged to be good for insiders.
[1] https://www.opensecrets.org/federal-lobbying/top-spenders
It seems like a clear case of systemic fraud to me. Am I missing something?
Also I am not able to find any fundoplication or LINX (43284).
Will add 43284 & other gastro procs shortly. Thanks!
Insurance companies each negotiate a rate for various services with hospitals. People pay different rates depending on the insurance they have, due to these different negotiated rates.
This creates a perverse incentive where hospitals want to list their "cash" price as being higher than the negotiated rates, otherwise insurance companies will come back to negotiate their rates down to the obviously lower cash price.
In reality, it's usually surprisingly easy to get hospitals to give significant discounts if you tell them you're without insurance and you'll be paying in cash. Patients without insurance can often negotiate their bills down to a fraction of the original list price by simply calling in and telling the billing office they don't have insurance.
It's obviously not a great system.
You have no position to negotiate and I have never got them to budge. I have tried and gotten pretty angry about it.
Short-term insurance is a waste of money because the rates did not appear to be negotiated at all. They paid 5% of the bill and stuck me with the rest.
The only reason to actually pay your bills is the hospital might eventually sue you. Its messed up.
Turned out the hospital was not in network, they charged me $15,000 (including $10,000 for a "level 5" ER room stay, which is twice the most expensive price listed on the OP's website and is 10x the local average price for that service, despite the fact that my experience could not possibly have been Level 5 service). Eventually they just sold the debt to a collections agency. I tried to fight but they didn't seem to care, and why would they? They already sold the debt!
Just because other countries medical & legal systems are different than the US doesn't mean they are inferior.
A country can have a fine legal system for locals that's difficult or prohibitively expensive to access for non-citizens living outside the country.
All the Americans end up going to my competitor, who is currently in the midst of three lawsuits which will probably sink the company. Two of the lawsuits are with clients I turned away simply because they looked likely to sue!
You can bet that as an American, you will pay substantially more than a local for many services simply because Americans have a reputation for this sort of stuff, and local businesses don't want to take the risk.
I really wish there was some kind of certificate saying "I have never set foot in a courtroom, threatened legal action, or hired a lawyer".
You can bet that as a black person in our town, you'll pay substantially more than white folks, because most of us understand that black people have a reputation for this sort of stuff and general trouble, and we don't want to take the risk.
I really wish there was some kind of certificate to let us know which ones are the docile blacks...
(Note: It should go without saying that this is a tongue-in-cheek response)
That said, if I'm wrong about that I'm interested in learning more.
Yes. Indian legal system is very inferior compared to USA. My family is fighting a garden variety land dispute case for over a decade. I cannot even imagine someone successfully suing a doctor here for malpractice while living in USA.
I'm a UK citizen, resident in Norway, who has visited Poland on business many time.
I stayed a night in the Krakow Neurological Institute somewhere between fifteen and twenty years ago, cost me about 100 USD. The ambulance that took me there was free.
A few minutes later we saw the helicopter lift from the hospital and head straight towards us. Down came the rescue equipment and Dr Bruno, who told us not to worry because "We do this all the time!". 10 minutes later he was ascending with the patient.
I learned two things: Doctors in Switzerland really do do this stuff all the time, and always have hiking accidents near well-equipped medical facilities that aren't trying to totally screw people over.
I'm pretty sure it was the best $2500 that guy ever spent.
Almost all.
Non citizens just pay a fee or are reinbursed later by their insurance or healthcare system. In many cases citizens from country 'A' can use healthcare in 'B' as long as their own citizens will be granted the same treatment in exchange when visiting 'A'. It depends on the treatises signed between the two countries.
Allowing foreigners to use the health care system for free is sometimes allowed (or even encouraged) if that protects the interests of the country.
There is no incentive for doctors to be efficient so they aren't. They order too many supplies, do too many procedures quickly (when doing them slowly would be fine, and cheaper, etc).
Price discipline is like gravity. It affects everything. In most American businesses subject to market forces, there is an enormous push to optimize every single little bit of the business to control costs.
This force simply doesn't exist in healthcare.
- medical malpractice insurance -> legal system
- big pharma/med devices industry
- doctors are paid higher in the US than in another countries
- billing staff overhead because of the insane insurance system
- highly paid hospital administration
- lots of middlemen that stay invisible because there is no price transparency
- shiny new buildings that are built by friends of the hospital administration
- Gold plating everything to avoid getting sued.
- Inflated medical school costs
- the price of a huge bureaucracy for billing people, chasing them, disputing it, agreeing rates with insurers, renegotiating rates with insurers, applying the right discounts, billing a dozen different state and federal programs for various bits, those being disputed, managing all that etc.
If you spent $0 on drugs next year, we would not save that much money.
If you want to cut spending, you need to cut spending on doctors and hospitals.
If you want sources for these numbers, here is the National Health Expenditure summary from the Centers for Medicare and Medicaid Studies:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
To be clear: I totally agree w/ you that the AMA is a cartel.
Big pharma has actually reduced the hospitalization costs over the past two decades.
Edit: can someone explain downvotes?. How is big pharma increasing hospital costs?
please take a look at this, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669633/
"The major empirical finding from this research is that medication use by Medicare beneficiaries is significantly negatively associated with hospital spending. Moreover, the cross-effect is quite large: each additional prescription drug fill reduces hospital costs by slightly more than $100 or about 5 percent measured at the mean level of Medicare payments in 2000 for inpatient hospital services for study subjects. "
Because up until a few weeks ago, people weren't allowed to see what hospitals charged until AFTER getting their bill. It was a ridiculous system, and I'm glad Trump got rid of it.
For example ultrasonic diagnosis of your frozen shoulder is 600 Euros in USA, 200 Euros in Finland and 80 Euros in Vilnius.
This issue is relevant, because European healthcare wont fix your shoulder, because it is a "cosmetic problem" and will disappear on its own in a year or two.
One issue: it looks like the search is not respecting the zip code for me if I change it. For example, if I search for a procedure using the zip code the site auto-populates, my results are great. However, if I change the zip code to my actual neighborhood here in NYC, I'm seeing results from all over the country.
The reason for this is that chargemaster price is a fake dollar price resulting from a broken incentive structure and process. Here’s a setup:
A hospital is working out a negotiated rate for aggregate services with an insurance company. The insurance company wants to pay less, and they’re willing to put the hospital “in network” and bring their block of customers with them by doing it. But the negotiators on both sides aren’t going to sit and figure out the “right” price of every procedure. That would take forever (and there’s dinner at a Michelin starred restaurant to go to after this deal is done), so they agree that they will just pay some percentage of the chargemaster price, say, 50%.
Over time, the hospital administrators say “we need more money for this” and realize they have a lever. 95% of their customers are paying negotiated rates that are a percentage of the chargemaster price. The percentage is locked in stone, but the chargemaster rate? Yeah. They can change that.
The insurance company cries foul at their Michelin two-star dinner the next month, and the hospital agrees to lower the percentage a little in the next contract. Now the insurer is feeling flush, and the hospital is making about what they were doing before from that 95%. The remaining 5% who were uninsured are hanging upside down and getting shaken for loose change.
The cycle continues, and, eventually, the negotiated percentage drops to something comical, like 12%, but the chargemaster rates have soared. In the end, a pair of Advil “costs” $68 and uninsured patients have nosebleeds from being hung upside down for so long.
But there’s a new restaurant to try out, and someone else’s personal bankruptcy is a small price to pay for no-fuss managed care...
(Note: Marketing and administration accounts for more than a third of health care costs in the US, which is to say that health care bloat and weight due to a multi-player adversarial privatized system accounts for more than 5% of our GDP, so the chargemaster isn’t the only reason for sky high healthcare costs in America.)
(Worked on hospital pricing reports since 2001)
I agree that the chargemaster prices are fake, but what you are proposing is:
Hospital: "Our insurance partners pay us a fraction x of Chargemaster charge X, so let's make C larger."
The insurer understands the game being played here, just like you do. It's not like the insurer doesn't also realize just like you do that the chargemaster price is fake.
The insurers are not going to say "Oh C got bigger this year? Well, let's pay more!"
More important are failures of competition in the marketplace, especially consolidation on the hospital side (most markets are now served by large hospital systems, so insurers cannot plausibly threaten to exclude hospitals from networks), the lack of exposure of consumers to most of the price, and the lack of incentives on the consumer side to search for cheaper prices (plus a general lack of any information about which facilities might be cheaper).
The hospital makes more margin off of people not covered by the insurer, the insurer is largely insulated from the change, and everybody comes away okay... except the uninsured patient who has no negotiating power.
The simple answer is that Americans really do consume significantly more healthcare than Europeans. The most straightforward signature of this is the fact that a much higher proportion of Americans work in the healthcare industry than any other large country. The US also tends to consistently lead on the highest utilization of cutting-edge technology (such as ICDs, insulin infusion pumps, linear accelerators, and small bowel transplant) at any given time.
Cost per inpatient discharge is exactly in line with a regression of European countries against average household disposable income. (The US having nearly double the household disposable income as Western Europe.) Rather than being some signature of American dysfunction, globally we observe hospital bills rising super-linearly with income levels. This strongly suggests that hospital costs primarily rise because of higher intensity of care per encounter.
The strongest counterpoint to this is that despite America's high healthcare consumption, that health outcomes are significantly worse than Europe. In particular in terms of life expectancy. But healthcare economists have known for decades that medicine, on the margin, has virtually zero impact on health.[2] The US is an extremely unhealthy country, especially because of obesity. No level of healthcare would ever be able to counteract that.
But again this disjointed relation between medicine and health is not an American-specific phenomenon. The ratio of healthcare spending between Norway and Spain is about the same as between the US and Norway. Yet Spaniards enjoys significantly longer life expectancies than their Norwegian counterparts.
[1]https://randomcriticalanalysis.com/why-conventional-wisdom-o...
[2]https://www.cato-unbound.org/2007/09/10/robin-hanson/cut-med...
I do not believe this is correct.
From the OECD, average length of hospital stay across rich countries:
https://data.oecd.org/healthcare/length-of-hospital-stay.htm
We pay more but we generally consume less. EDIT: let me add this comparison of health prices across countries from the Health Care Cost Institute. See Table 1:
https://healthcostinstitute.org/hcci-research/international-...
Our prices are higher.
The US is an obese country, but you will find if you look that obesity rates are similar or worse in (e.g.) Mexico and some Gulf States (I think the UAE though I don't have a source for you).
We are not a wild outlier in terms of measured unhealthiness. Life expectancies here are lower though, despite vastly higher expenditure than other rich countries.
There are important failures on the supply side of the market:
From the OECD, we have fewer hospital beds per capita than most rich countries:
https://data.oecd.org/healtheqt/hospital-beds.htm
We have fewer doctors per capita than most countries:
https://data.oecd.org/healthres/doctors.htm
Failures of competition throughout the market (including hospital consolidation) keep prices high. We do basically zero evaluation of cost effectiveness.
Just look at the life expectancy of France and Germany to disprove your theories.
The big difference between the American healthcare system and the one in these countries is that people don’t have to worry about the bills, which means healthcare providers have a much bigger incentive to learn what cost benefit analysis means.
Let's use France as a comparison point since you mentioned it. Household disposable income in the US is about 36% higher than France. That's about equivalent to the wealth gap between France and Slovenia. The US spends about 70% more per hospital stay than France, and very similarly that's almost the exact same spending gap between France and Slovenia.
The point being it's easy to ask "why does the US spend more than Western Europe?" But, analogously you should also ask "why does Western Europe spend more than Southern and Eastern Europe"? And the most clear answer is because wealthier countries tend to spend a higher percent of their income on healthcare.
[1] https://i0.wp.com/randomcriticalanalysis.com/wp-content/uplo...
I've seen the prices of procedures and drugs in France and in the United States (that is, before insurance, because no-one really worries about the price of healthcare in France given you get reimbursed more the more expensive your procedures are, which is how things are supposed to be), and it's definitely not 36% more expensive. Everything is at least 10 times more expensive.
I find reading comment threads containing comments that don’t seem to account for the literal assertions made in the previous comment tend to be difficult to follow and quickly degrade.
Can you go into a bit more detail about how exactly this incentive linkage works?
I believe this is a completely different way of looking at things than in the US. The average EU citizen doesn't really think that the monthly medical deduction from his salary is just for his use or it's his own insurance, it's only a contribution to the whole system.
Because the US does provide for tax funded healthcare for the old (Medicare) and the pregnant/poor/disabled (Medicaid). The [cost of these programs](https://www.kff.org/medicare/issue-brief/the-facts-on-medica...) is greater than US military spending.
To do a real analysis you'd need to see a breakdown of where the money goes. What percentage is to a physician's salary, hospital overhead, insurance premiums, etc. for both countries and see where the big disparities are. My guess is, everything is more expensive on the US side, including salaries, and adds up to the big difference in price.
Universities overcharge in the US. The medical education costs upwards of $800K if you include the cost of lost opportunity had you gone into a different field and worked those years instead. So doctors need higher salaries. That, combined with idiotic market dynamics around medical supplies, means that all medical costs are higher. That in turn means everyone absolutely needs insurance or risk personal bankruptcy.
The ultimate problem is this planned economy mandate of "full employment". It is in no individual's interest to declare that their own job is counterproductive, otherwise they'll starve. So they hang on performing in their own little niche, sucking resources out of the system so they personally can continue living a dignified life. We're stuck in a paperclip maximizer, and the healthcare industry is one of the best small-scale illustrations of this.
Other countries do just fine with much less.
https://www.healthsystemtracker.org/brief/what-drives-health...
The vast majority of the difference comes from just the raw cost of inpatient and outpatient care. Even if you were to completely zero out the administrative costs per capita, you'd hardly make a dent in bridging the gap.
I am interested to understand what makes the "raw" costs so wildly different.
When my son had an infection in germany, we went to the equivalent of pediatric urgent care and after seeing the nurse, having bloodwork done and a few different 15 minute sessions with the physician we came to the end of the visit with the doctor, they apologized that we had to be charged the full uninsured rate and that a bill would be given to us later that we could use to have our insurance (they could not bill our insurance internationally.) We paid the 50 euros and asked what the total amount would be, assuming that was the co-pay. There was a lot of confusion because the 50 euro wasn't the copay -- it was the full-freight amount. Getting a single 15 minutes with a doctor, let alone the prep with the nurses and bloodwork being rushed would be far more than that in USA.
This study says over one-third of all US healthcare costs are administrative.
https://www.reuters.com/article/us-health-costs-administrati...
I want to be able to make a case for a single payer system in the U.S., but I think to be effective it's a comparison of costs and outcomes that needs to be had. In the data linked above, we're told that the 'inpatient and outpatient care' is significantly higher than in 'comparable countries.'
I believe it. But isn't 'inpatient and outpatient care' just about .. everything that goes into a health care system aside from the paper pushing and insurance pieces? And are hospitals really breaking that stuff out ?
Someone in favor of the U.S. system would say, ah hah, that's because we in the U.S. have access to better care, and more sophisticated technology, than in France or Germany, and also we don't have long waiting lists. I don't know the technology claim, but I've seen the wait list claim and I do think it's true when comparing the U.S. with Canada or the UK (the latter two have long waits for essential surgeries compared to the U.S.)
How would one counter this claim?
Looking at the article, it's pretty hard to understand what what's actually costing more. "Inpatient and outpatient care" is a pretty enormous bucket and probably accounts for a whole lot of salaries, services, and such of pretty much any job title with "medical" in it.
Admin, does in fact represent the largest % difference... but it's not clear what's grouped into it. I assume it means government departments, insurance firms, external legal/finance services. I don't think the data refers to a salary-bysalary breakdown of costs.
Sometimes it's best to look at these things from the ground up. Doctors, nurses. How many? How much are they paid? Is the diff more or less than mean diff? If no, move on, If yes, dig deeper.
You really can't even rely on price data to tell you much. Most of these markets have a broken or absent price system. The underlying answer though, inevitably will likely be "because they're run differently."
Question: What do we mean by "inpatient and outpatient care"?
How can in/out patient care be so vastly different in cost?
Source: Me. just made the second appointment with a specialist within a week thanks to pain, appointment is tomorrow
This is the kind of comment that immediately classifies the commenter as never having lived outside the US and/or not reading anything but US news sources. And with the wilful blindness to how exactly those gatekeeping referrals are present in most every single healthcare plan in the US.
http://www.econ.yale.edu/seminars/strategy/st03/nicholson-03...
https://econtalk.simplecast.com/episodes/keith-smith-on-free...
Practically any US medical practice is going to have huge staffing overhead for the people who maintain the accurate billing records and wrangle with insurance companies.
I can directly compare with the French system: Doctor has a receptionist, you pay him cash right there on the spot, and he’s very limited in what he can do. E.g. he has to send you to the pharmacy to buy your shots, but he’ll administer them. When it’s all done, you fill out a crapload of forms, staple all the receipts to the stack, and your employer (via insurance) returns somewhere between 60-80% of it.
I have long maintained that moderate reimbursement for outpatient care would be a huge improvement for the US. At the same time, there’s a fairly large entrenched interest that wouldn’t like this at all.
https://www.payscale.com/research/DE/Job=Physician_%2F_Docto...
https://www.payscale.com/research/US/Job=Physician_%2F_Docto...
Edit: Looking at some german articles, maybe they did not convert from eur to usd, ~80,000-100,000$ (depending on expertise etc) seems more likely for a dr working at a hospital (which is still low imho compared to US salaries...).
https://www.arzt-wirtschaft.de/wie-hoch-ist-das-gehalt-bzw-d...
This is more accurate:
https://www.medscape.com/slideshow/2020-compensation-overvie...
That is likely too low.
The Centers for Medicare and Medicaid Services provides a National Health Expenditure estimate annually. [1]
Physician and clinical services represented $772 billion out of about $3.8 trillion, so more like 20%.
Hospital services are the other big one: about $1.2 trillion.
US physicians are paid terrifically relative to their counterparts almost anywhere else, this is especially true for specialists.
In fact, physicians represent about 15% - 16% of the top 1% of income earners in the US. See table 2 from this paper: https://web.williams.edu/Economics/wp/BakijaColeHeimJobsInco... which was written using tax return data, not, e.g., self-reported income data.
[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
I do think this transparency initiative will result in more consistent costs but not necessarily net lower costs.
Comparisons to other countries that are smaller than the united states are somewhat apples to oranges. There are a lot of factors that are glossed over when someone says "costs are 5x higher in the US than my country" including real estate, energy subsidy, and so on. Its a deep well.
I tried to total the cost of the care my son received when he was born, had we been American. I stopped counting at $1million.
Being in the UK, I even got a few meals at the hospital canteen thrown in. Not to mention the time in nICU etc. It is horrifying that people have to compare prices and haggle for care anywhere on earth.
But the US system is tricky because while it is an huge mishmash of layers of middlemen and clearing houses taking a slice of the pie, those layers also employ a huge number of Americans across the country. It would be extraordinarily difficult (both logistically and politically) to rip all that out in one fell swoop. I feel like the only possible way to bring in socialized medicine in the US would be a gradual expansion of opt-in 'Medicare for All' or something along those lines.
So yeah, expand and improve existing programs until they're universal and comprehensive like the NHS. Sane approach.
Appendectomy: MSDRG 343: at Kaiser in Santa Clara: $56,000
Appendectomy: MSDRG 343: at Holston Valley Medical Center, TN: $4,700
Our healthcare system is even more broken than I ever imagined.
You may be able to find similarly insane examples at other hospitals, but Kaiser is vertically integrated: generally Kaiser doctors send Kaiser-insured patients to Kaiser hospitals.
I am not sure how they reach their measure of a "price" here but it is entirely possible it's unusual and or different.
Again you can probably find something similar at non-Kaiser hospitals (Just for fun... check the Sutter system in NorCal - it's extremely expensive), but Kaiser is not the reason you should think this is insane.
> RESULTS
> Fifty laparoscopic appendicectomies were performed. Median operative time was 60 min. The median total operative cost of laparoscopic appendicectomy was £906. Median equipment cost for laparoscopically completed cases was £254. Median total in-patient cost was £1617 (range, £880–£3360). This compared with a mean re-imbursement of £1981 representing a [hospital] cost benefit of £233 per case (P = 0.0009).
> CONCLUSIONS
> Despite a liberal use of disposable equipment, laparoscopic appendicectomy can still be performed within the confines of the national tariffs. There is a considerable variation in the cost of this procedure, and it may be possible to reduce costs by more stringent use of disposable equipment and standardising recovery protocols.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966171/ [2] https://www.theguardian.com/society/ng-interactive/2016/feb/...
You guys are swimming in cash.
Anecdote aside, your point stands. Shopping, across state lines for surgery is ridiculous.
How do you plan to keep the data current?
Also, in the US, is a patient realistically able to say, “Hospital X is able to get my compound fracture surgery done for 65% less. Match it or I walk”, especially when insurances have negotiated rates.
Or is this only useful for people with no insurance?
Also, very useful for cash pay.
I ask because this space has always been interesting for me. Funny enough, I helped build almost the exact same thing at a hackathon (https://devpost.com/software/liform), but the project didn't pan out after that due to our team's lack of medical knowledge. So I'd love to learn from your experience processing this data into a usable form.
> And like other dream jobs I learned about, it’s not enough to survive on: During
> off-seasons, Krumbholz also works as a substitute teacher and an aquarium dolphin
> tank cleaner; since being on university health insurance would mean she’d constantly
> lose it during the off-season, Krumbholz decided to stay on the state exchange
> instead.
(majority of) people with jobs have no idea how bad/expensive healthcare really is. they have excellent insurance coverage and they pay very little for it. if we make them responsible for buying their own it'll be impossibly expensive. but this is exactly what they need to realize so that we can have the political movement to overhaul the entire system
That belief is the problem. You pay for it with reduced salary. Problem is that this fact is being hidden. Then you also have your employer choose insurance plans for you but their selection criteria are most likely for their own benefit.
I've recently found I now need to add another filter to this: "WHO is your insurance through?" because apparently even 90% employer paid health insurance through UnitedHealthcare still sucks compared to inferior coverage through BlueCross or Aetna. I had to switch primary care doctors for everyone in my family (me, wife, kids all had different docs) because none of them were in network with United. Confused by this, I called around. I found out doctors offices loathe dealing with UHC due to UHC's reluctance to pay or the generally obnoxious claims process. Their "in-network" providers is contained to a much smaller list of providers that put up with their bullshit. I'm seriously considering leaving my current employer (which I'm very happy with) for this reason alone.
Lack of reliable (or any) health insurance is the #1 reason I don't take contract jobs even though they're more attractive to me.
This is not how freedom works. Your argument is akin to saying "freedom from hearing uncomfortable opinions" benefits more people than "freedom of expression" does.
On the broader level, I got to experience healthcare in the US both as a broke-ass immigrant child and as a working adult. It ranged from good to amazing in terms of availability of appointments, treatments, quality and comfort. Night and day beyond what I experienced in the USSR as a kid. So while people are shitting on the system we have, many people find it excellent and amazing and we like the freedom to continue enjoying it.
However I recall the night my son was born - the facilities, staff and resources of the hospital were unmatched - the mother and baby would not have the same experience anywhere else in the world.
My wife works in the ER - they constantly use procedures and deploy resources in ways that would be considered impractical elsewhere in the world.
For example: an 65+ year-old patient comes in with a specific complaint. It could be cause A or the more rare but serious cause B. It takes imaging to determine whether it's A or B. Elsewhere in the world, they just assume it's A as the patient is "old" because it's financially impractical to test for B. My wife on the other had has no constraints from ordering the imaging test even though 9/10 times it's "wasted" as it just confirms A. But the other 10% of the time, it saves the life.
We make a different tradeoff in the US, some of us prefer this trade off.
This just plain isn't true in general. I grew up in the US with probably the best insurance of anyone I've ever known. I've also lived in Sweden with the state-run insurance (without any private addition). I've had great care in the US. I've had great care in Sweden. In fact, my care in Sweden has honestly probably been better in my cases including where I had overuse injury to my knee due to sports where they really could just say "well quit running so much and let your body rest and leave the healthcare system to those not actively inducing their own injury", but they did not. Fast MRIs, fast diagnosis, fast help, fast everything. I understand this is entirely anecdotal, but the fact is there are many much cheaper systems out there run by governments that actually function _better_ than the US system even for those in the US with good insurance.
We had a wonderful experience with the birth of our daughter, but I have no idea how I could claim it was better than anywhere in the world. I'm asking because you seem to be making a low-hyperbole claim here: what is your basis for saying that? Particularly, when the US has some of the worst metrics for infant mortality, birth weights, and mother mortality rates in the developed world.
> My wife works in the ER - they constantly use procedures and deploy resources in ways that would be considered impractical elsewhere in the world.
Does this actually lead to better health outcomes? The US ranks low in the developed world in many health-related areas. Some of them are at least in part due to cultural issues and it is completely fair to attribute to our healthcare system. But some of them like our rates of medical and lab errors clearly are. I'm genuinely looking for data to support the idea that the tradeoff you mentioned actually exists.
I live in Canada where I am enrolled in the provincial health plan. If a doctor recommends a test or treatment I get it. Cost isn't a consideration. My age isn't a consideration. Please don't spread lies about how universal healthcare works. Unlike insurance in the US, if the doctor orders it, it is covered by the healthcare system here.
Truth: I may have to wait based on a triage system.
If the doctor doesn't recommend a test as necessary or I don't want to wait for my place in line, I can go to a medical clinic that offers these tests privately and pay/have my employer provided secondary coverage pay.
In that way it turns out that we don't have to make the tradeoff.
I've had the best insurance I could buy in the US, and now I have the standard health care that every person in my Canadian province gets. My experience, which is backed up by studies, is that I am healthier, and the population in general is healthier under the Canadian system.
According to this the US is mostly in the high top 10 for outcomes in cancer and cardiovascular disease treatment outcomes:
https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...
But the US spends more than double the OECD average per capita to achieve those marginal gains:
https://upload.wikimedia.org/wikipedia/commons/thumb/0/0b/OE...
There's an argument to be made that the cost overruns are paying for better outcomes, or maybe the outcomes have some sample bias due to Americans being less healthy, or sicker people are seeking treatment in the US.
But on the other hand, the gains are so marginal that those costs might also be due to significant corruption and regulatory capture.
In any case we have public and private hospitals. Paying an insurance for assuring a "premium" service with better rooms or faster treatments (closer to the US system) is also an option.
Despite right-wing propaganda that we're all flocking to the states for care (never met a single person who has even considered that), or that we're all dying on years long wait lists (there is an element of truth to that, but it's a triage system. So cancer patients get priority for surgery before the skier who blew his ACL).
I still have yet to meet a single person who doesn't think the US system is batshit crazy.
Canadians recognize that their system has problems, and can be improved (which is true of ANY complex system). But they also don't think that the US system is functional or desirable.
I know that the nearest border crossing to me regularly has ambulances waiting for people that preferred to travel sick or injured than seek healthcare in the US. In other words, people literally flee the country to avoid being treated in the US.
The problem seems to be figuring out a revenue model, and translating all the medical terms in to human.
Comparing just the price of a hip replacement is difficult, because there are so many other services that will bundled in with a hip replacement (anesthesia etc) that may not be represented in the service price alone.
The "average cost by diagnosis code a patient comes in with" transparency requirement is an attempt at solving that, but doesn't differentiate between insurance plans.
Also, I love OpenStreetMap, thanks for your work on that!
The average prices for common procedures is on the 1045 sheet
I have my gripes with California but I love that they did this
Side note - I'm a long, long time OSM fan and contributor. Thanks!
https://www.dolthub.com/repositories/dolthub/hospital-price-...
You get paid based on the percentage of rows you contribute to the dataset. So if you fill in 20% of the rows, you get $2,000.
More details here:
https://dolthub.awsdev.ld-corp.com/blog/2021-01-14-hopsital-...
Turquoise Health could be solving this need gap - 'How much will I be charged for my treatment'[1] posted on my problem validation platform.
You're welcomed to explain how Turquoise Health helps solve their problem in that thread.
[1]https://needgap.com/problems/122-how-much-will-i-be-charged-... (Disclaimer: It's a problem validation platform I created).
I get it that it's an expensive procedure, but OH MY.
It might be that the price is that insane elsewhere, but Kaiser may not be the best way to judge.
I have taken extra measures to ensure that myself and my family are healthy in the last year and with a tax-free HSA account that is invested into ETFs, I am literally printing dollars just by following basic principles of being healthy.
I was sick often as a kid and after finding a diagnosis I’ve been performing well among my age peers. Thank you Finnish healthcare. Couldn’t imagine how much it sets you back cognitively to have health issues as well as financial issues burdening your mind 24/7. Completely avoidable pain and suffering purely for profit.
And are you licensing out cpt codes from the ama? IMHO the AMA and their copyright of CPT codes is the biggest setback to progressive change, transparency, and adaptive change in tech... Payers and well funded companies can afford licensing, otherwise they will strangle you with lock down...
I once went to a doctor for vaccinations before traveling. The nurse said "You need X, I recommend Y, and the CDC recommends Z." I responded "great, let's get X right now. Not sure about Y or Z - how much do they cost?"
The question just didn't compute. No matter how I phrased it ("just want to price compare" ... "there's a bunch of travel clinics and I'm trying to get this cheaply" etc), I couldn't make myself understood.
The NP ended up coming in to give me their "anti-vax" spiel. I had walked in to a hospital wanting a vaccine, and asking about costs was so foreign to them that they thought the only reason I could hesitate to get a vaccine was anti-vax sentiment.
All this to say - this tool is very much needed, and has the potential to do a lot of good!
https://www.econtalk.org/keith-smith-on-free-market-health-c...
https://one.walmart.com/content/usone/en_us/company/walmart-...
:-)
You can pay for the trip, get the best care (it is a really good, international level, hospital) and still have some loney left.
There are laboratories even at walking distance of the USA haha ( https://www.google.com/search?tbs=lf:1,lf_ui:4&tbm=lcl&q=lab... )
$298.00
$7,830.76
$7,299.85
$10,243.23
$13,964.19
---
How are these even comparable?
My example of a magical 12x increase given single exact same procedure coded identically, means I find a price increase of ~43x from $300 to $13,000 between different hospitals quite believable.
The FTC has challenged a lot of hospital mergers. They are not always successful, but they do challenge them.
Source: healthcare/competition economist.
> isn’t an MRI and MRI?
Source (one of many): https://www.reuters.com/article/us-usa-trump-drugs/white-hou...
https://www.indy100.com/news/donald-trump-bad-things-list-b1...
There are 55 things on the list. There’s a mixture of things he said and things he did. As president, his words have real consequences, so drawing the line at “things he said” is strange.
One of the significant changes that the tax reform brings is an increase in the cost of capital raised in the form of debt. That is a good thing. The deductibility of interest on corporate debt creates an enormous distortion that causes firms to favour leverage, which leads to greater instability in the economy. Should interest be tax deductible? Well, whether or not you think it should be, it is. And so reducing the corporate tax rate makes that deduction less valuable than it was before.
The tax reform is hugely regressive in reducing the top marginal tax rates for high income earners. That is a giant negative IMHO, because wealth and income inequality are a huge problem in American society. So, personally, I believe the only good from the tax reform is on the corporate taxation side by, effectively, making things a little more efficient than they were before.
Other things that I think were a positive:
1. Rejecting Chinese firms' from the 5G network build-out. His diplomacy and trade policy were really random, but this was one move that worked out well.
2. Operation Warp Speed. While Hillary Clinton likely would have done a FAR, FAR better job of handling the pandemic overall, credit is due to Trump for getting behind the advanced purchase of billions of dollars worth of vaccines before they were even approved.
3. Greatly increasing the standard tax deduction for low income earners. "For income earned in 2020, single people pay no income tax on their first $12,400, heads of household on their first $18,650, and married couples on their first $24,800." [2]
Again, it's too bad that all the insane stuff he did and all the things he neglected will overshadow his accomplishments. History will likely judge Trump harshly, which I think is richly deserved.
[1] https://pubs.aeaweb.org/doi/pdf/10.1257/jep.32.4.73
[2] https://www.theatlantic.com/ideas/archive/2020/12/the-things...
1: https://www.inc.com/bill-murphy-jr/president-trump-just-sign...
However, what on earth has this got to do with aviation?!
> authorizes $1.68 billion for relief for Hurricane Florence, which hit the Carolinas last month;
Would it be possible to create a subscription-based health network that was vertically integrated and provided just basic outpatient needs? Charge $9/mo or something ridiculously low and encourage everyone to check their health often and maintain healthy lifestyles?
Use automation to reduce costs. Then gradually increase the scope of care.
That won't help with surgery, cancer, childbirth, etc. right away, but it might create a gravitational shift that puts swaths of expensive general practitioners out of business, creating excess supply and lowering the range of what insurance covers. That might greatly reduce costs.
We have to eat away at this bloated, inaccessible system somehow.
Most of what we need to do is just remove the monopoly rules.