My surgery bill, and the implications for American healthcare

I’m not a doctor, of course, nor do I play one on television, but I know that there are physicians among the readers here. They, as well as non-doctors, particularly those in countries with government medical care, might be interested in the itemized statement I got for my hernia surgery exactly a week ago.  The total bill was $64,476.34.  $513.00 of that was for the curbside COVID testing required before I went into surgery during a pandemic, and the remainder, totaling $63,963.34, was for the surgery itself —including all the supplies and drugs.

Here are the bills; I’ve removed personal information. I won’t of course have to pay more than a small fraction of these costs, as I have a good medical plan through the University (as well as Medicare), but those without insurance and Medicare would have to pay it all.

The COVID testing:

And the surgery bill (below). What impressed me was the high cost of anesthesia—nearly ten thousand dollars—as well as the mesh that’s in my belly to hold my guts in ($2,421.37 for a 10 x 15 cm piece), and also “robotic supply,” which I take to be whatever stuff they had to attach to the robot to operate on me ($9,657.00).

I also didn’t know that the operating room is billed in 15- or 30-minute increments, at $2,284 per fifteen minutes after the first half hour (nearly $12,000 for 30 minutes). Presumably that covers the costs of the surgeon, anesthesiologist, and other personnel in attendance—and, of course, profit to the University of Chicago Hospital.

Look at all the drugs I got: 24 of them! I think the Propofol is what put me to sleep, but as for the function of the rest, well, as I said, I’m not a doctor. I have to say that even a dollar for two acetaminophin (Tylenol) is way too expensive given that I can buy then for a bit more than 1 cent per tablet at Walgreen’s.

At the end is the superglue they used to close me up (“Adhesive Dermabond mini”). They didn’t use any stitches on the outside, so there’s still a veneer of glue over each of my three robotic punctures that will wear off. That glue cost $118.23.

TOTAL AGAIN: $63,963.34

I could look up all the drugs, but I’m not sure that would be good for me.  I did look up Sugammadex, the most expensive one ($691.16), which Wikipedia describes as “a medication for the reversal of neuromuscular blockade induced by rocuronium and vecuronium.  in general anaesthesia. It is the first selective relaxant binding agent (SRBA).”

And of course I had to look up “neuromuscular blocking drugs”, which are these:

In clinical use, neuromuscular block is used adjunctively to anesthesia to produce paralysis, firstly to paralyze the vocal cords, and permit intubation of the trachea, and secondly to optimize the surgical field by inhibiting spontaneous ventilation, and causing relaxation of skeletal muscles. Because the appropriate dose of neuromuscular-blocking drug may paralyze muscles required for breathing (i.e., the diaphragm), mechanical ventilation should be available to maintain adequate respiration.

I guess I was intubated, though I don’t see any charge for tubes.

Now, can you know these prices in advance so you can comparison shop among hospitals? The answer is NO. While hospitals differ drastically in their costs, it would be nearly impossible to get a figure for the entire operation in advance. Some hospitals, like the Surgery Center of Oklahoma, will quote you a flat price (and for them, my redo surgery would have been free), and that price, for hernia surgery similar to mine is, I’m told, about $4,500: only 7% of what the bill was above. Nor are these cheaper hospitals worse at what they do: there seems to be little correlation (or even a negative correlation) between the price of a procedure and the quality of the facility and the doctor. (My doctor at the U of C, by the way, was excellent and has a superb record, but more on doctor-shopping later.)

What about the costs above? Are those the sticker costs that then get discounted when billed to the insurance companies (i.e. are they they the so-called “Chargemaster list prices” for each item), or are they the already-discounted costs given to my insurance company?  I have no idea.  It’s as if you went to the grocery store and there were no prices on the food items, and then after a month you get a bill saying, “This is what you have to pay for groceries.”  After talking to my doctor, who will answer your questions below, I’m convinced that the entire medical system is set up not only to make profit, but to prevent patients from exercising discretionary pricing and comparison shopping.

Why are prices so high? Because there is no incentive for doctors and hospitals not to raise prices given that most patients have insurance, don’t know what they’re going to pay, and because hospitals negotiate a flat percentage rate for reimbursement, which differs among insurance companies—a rate that applies regardless of what a procedure costs. So, for example, if the insurance company negotiates having to pay 50% of the “Chargemaster price” used by the hospital (these rates are secret, of course), then the hospital can simply raise the price of its procedure, so it will get more money from the insurance company and the patient’s co-payment.

Things aren’t made better, I’m told, by the Affordable Care Act, which sets a roughly 20% maximum on what each insurance company can keep for profits, salaries, and operating expenses, with the rest going for their customers’ healthcare. That leads to an inexorable raising of premiums and doctor/hospital prices, which go up in tandem. There is no brake to this system.

Can you at least comparison shop among doctors and hospitals to see who has the best record of surgical or medical outcomes? The answer is also a big NO. Those records are required to be kept by law, but patients have no access to them. You have to either find a doctor who has access to these records (they have to pay for such access), or rely on word of mouth.

What’s the solution? Government insurance may help, but isn’t a panacea. In Canada, I’m also told, prices are lower, but the country is hemorrhaging doctors because of the low salaries, resulting in a severe doctor shortage and interminable waits for medical care except in emergency situations.

Now this is a very complex process, but American healthcare appears to be broken in ways that very few of us know about. I may have made a few errors in this post, and will strive to fix them.

Also, my physician, Alex Lickerman, who’s a private primary-care doctor and deeply concerned with the rising costs of American medical care, has consented to answer readers’ questions in the comments below as he has time. You can ask him about how to comparison shop, why American healthcare is a big rip-off, what he sees as the fix for American healthcare, and why the Canadian system, at least, isn’t working very well. (Much of the information above I got from him.) Or ask anything else.

This started out as a simple presentation of my medical bill, but may wind up as a discussion of the outrageous costs of American healthcare, and whether there’s a good fix. Have at it, and do pose questions for Dr. Lickerman.

 

169 Comments

  1. BobTerrace
    Posted November 10, 2020 at 9:54 am | Permalink

    My pacemaker/defibrillator replacement in June was billed at over $135K. I was home by lunch time.

    Medicare paid only a fraction of the stated bill and I paid nothing.

    • Randall Schenck
      Posted November 10, 2020 at 10:01 am | Permalink

      That is what makes everything so complex. The bills from the hospital or doctors is never what is paid by medicare and or your insurance company. Also you have to wait months to see the whole business because medicare puts out their statements every three months. Insurance companies usually monthly. You can never go by a bill itself even if you ever see that.

      • Posted November 10, 2020 at 1:36 pm | Permalink

        I also had a pacemaker fitted. A more complex one for several reasons; first because it required multiple excitation leads to the ventricles,and second because the medical team were kind enough to fit a particular model of pacemaker that would allow me to resume my scuba diving hobby. It was a four hour operation. The cost to me was absolutely NOTHING as this was done under our National Health Service . I live in England

        • jezgrove
          Posted November 10, 2020 at 5:26 pm | Permalink

          You probably paid something via your income tax, but other taxpayers chipped in the rest according to their ability to pay. Margaret Thatcher may have denied that there is such a thing as society, but there is. And although our health needs and the ability to pay for them are not perfectly aligned, at least the NHS is there for everyone regardless.

  2. Randall Schenck
    Posted November 10, 2020 at 9:57 am | Permalink

    I suspect the cost for your procedure will vary allot as you go around the country. Chicago is probably at the higher end of the price range because it’s Chicago. Since you had a similar procedure just a short time ago, I wonder how it compares to this one.

    I am in the process of getting one implant currently and the whole thing takes forever. There is bone grafting and lots of waiting. I think the whole thing is taking nearly a year and the cost – 5 to 6 thousand. And this is one tooth.

  3. TJR
    Posted November 10, 2020 at 9:57 am | Permalink

    Bloody hell.

    Sorry, can’t think of anything more cogent than that.

    I mean, bloody hell.

    • jezgrove
      Posted November 10, 2020 at 10:50 am | Permalink

      Indeed – unbelievable!

  4. Charles A Sawicki
    Posted November 10, 2020 at 10:01 am | Permalink

    Shows what will happen to the poor and middle class if Obamacare is gutted by the SCOTUS. Ironically, it will result in the closing of may small hospitals in the hinterlands of Trump country.

    • Hempenstein
      Posted November 10, 2020 at 10:18 am | Permalink

      Tangentially related, my colleague @ U SDakota told me last night that the hospital there in Vermillion is building an annex to handle all the COVID patients.

    • Bob
      Posted November 11, 2020 at 7:03 am | Permalink

      I don’t see how that follows. Did those hospitals exist before Obamacare?

      There are three types of medical expenses, four if you count hospice. 1) maintenance, 2) catastrophic, & 3) long term conditions like diabetes. We can argue about what goes in each category. We will still want to help poor people with them.

      We know from the history of discretionary procedures like LASIK that markets can work in medical care. I bet markets would help with categories 1 & 3. Insurance is only appropriate for the second.

      Experience with insurance paid car and home repair indicates to me that insurance distorts prices generally. Nobody seems to have any incentive to make car repair less expensive. Quality is iffy, especially with home repairs.

      Experience with a single payer system indicates that they ration care with waiting lists. Organizations like the VA can get pathological.

  5. Joseph
    Posted November 10, 2020 at 10:04 am | Permalink

    In certain situations (cosmetic surgery, laser eye surgery, some dental procedures) there is more transparency in the pricing which subjects the procedures to normal market forces. Some argue that this could be scaled up to include many routine surgical procedures like Meniscus repair. This seems to make sense. In most areas of life, when businesses compete, consumers save. What are proponents of a free market health care system getting wrong?

    • drosophilist
      Posted November 10, 2020 at 11:32 am | Permalink

      Hi Joseph,

      The “free” in “free market” means that both the potential buyer and seller are free to walk away from the transaction.

      I have to eat in order to live, but I don’t have to eat any particular food. If pineapples are too expensive, I can buy some pears instead. Knowing this, the pineapple seller has an incentive to lower the price of pineapples so that I will buy some.

      Not so with health care. If my doctor says, “You have cancer, and your only hope of survival is chemotherapy, which costs $100,000,” what am I going to say? “Thanks, doctor, but I can’t afford this, so I’ll get a $5 bottle of Tylenol instead”? It’s essentially a hostage situation. I am not free to walk away as long as I value my life and health.

      • drosophilist
        Posted November 10, 2020 at 11:38 am | Permalink

        Note that all your examples – “cosmetic surgery, laser eye surgery, some dental procedures” – prove my point. I am free to refuse to have them if I can’t afford them. I can choose to live with less than perfect teeth/breasts/nose; I can use eyeglasses or contact lenses to correct my eyesight. I cannot choose to live with untreated type 2 diabetes or cancer or heart disease, at least not if I want to stay alive for long.

        • Joseph
          Posted November 10, 2020 at 1:38 pm | Permalink

          Thanks for the reply. I take your point. But since so much of the problem with Jerry’s example has to do with the fact that the cost of the service isn’t/can‘t be disclosed to the consumer in advance, it seems like a move towards a market based approach wherever possible might clean up the landscape in general. Perhaps this could include hernia surgery as well. I don’t know.

          A friend of mine had meniscus surgery in India a few years ago. It was non life threatening and not time sensitive and therefore he was able to shop around for a better price which, not surprisingly, happened to be overseas. It seems like a market based approach could work in any area where costs can be accurately predicted (perhaps an estimate, +/- 10%). Contractors gives estimates for home repairs everyday and mechanics do the same for car repairs. Human life is obviously a very different thing.

          But as it stands, if I go to the doctor and he orders blood work or an MRI, I have no idea how much any of it will cost until I get the bill. And no one else seems to know either. Do the costs of such diagnostic procedures really fluctuate that much? There’s the overhead of the facility figured into the cost, including the wage of the technicians…..additionally there’s the cost of the equipment etc. I think we’ll always need insurance to cover serious medical issues. But the routine stuff seems like it could be streamlined.

    • jezgrove
      Posted November 10, 2020 at 5:31 pm | Permalink

      I’m not sure what happens elsewhere, but in the UK when private sector surgery goes seriously wrong the private hospital doesn’t have the resources to fix the problem and the taxpayer-funded NHS picks up the pieces.

  6. Posted November 10, 2020 at 10:05 am | Permalink

    Woah. I can’t even fathom this, coming from NHS-land. I did see a suggestion that we Brits should be given a bill for what things would have cost, to show us the value we should place on having it all for free.

    My question is very silly and obvious, but it would be enlightening to hear an American doctor’s view of it: why can’t the US have an NHS like the UK? Pretty much all free- and in Scotland, but not England, even prescriptions are free. Of course, some would say the NHS doesn’t work that well, but I think it does (it’s saved my life so it’s doing something right!). I suppose it would be too ‘socialist’ for America. But practically speaking, why can’t America have such a health service? Or can it, but politically it wouldn’t gain traction?

    • Posted November 10, 2020 at 10:16 am | Permalink

      The answer quite simple: to do as you suggest would require a change in the law, and laws are made by politicians. The politicians don’t work for “us” — obviously they work for the moneyed interests. Those include for-profit healthcare.

    • Randall Schenck
      Posted November 10, 2020 at 10:17 am | Permalink

      My reply to you is just based on my limited knowledge but I think some day we will have a similar system. The reasons we don’t are many. Doctors in this country make much more than they do in other places around the world. Maybe twice as much but it depends on the specialty and all that. Also the private insurance business in this country is very bit and they like it the way it is. Big pharma also likes it this way. There are not many controls and the prices go up way more per year than any place else. This virus business is going to make our system look even worse. Where I live the hospitals are full up, at max and the patience just keep going up. My guess is the system is broken.

      • Posted November 10, 2020 at 12:49 pm | Permalink

        Specialists do. GPs do not make that much, especially if one considers the time and money and effort required to become an MD.

        My best friend from high school became a doctor (and a very good one).

        He didn’t get his first “real” doctoring job until he was 32 — 8 years after I had been working as an engineer (he is a specialist). And he wasn’t dilly-dallying. And those internships really are as hard as you’ve heard (36-hour shifts, for instance), at least when he and his wife (also an MD) went through.

        Who (of the top cohort of intelligence and drive) is going to defer that much income and lost opportunity cost to become a doctor — unless there is a substantial reward at the end of it?

        • Nicholas King
          Posted November 10, 2020 at 4:17 pm | Permalink

          In a similar thought to jbillie, I’m afraid you may not yet have the entire bill.
          In my experience the Anesthesiologist may bill separately for his skills. And the surgeon for his.

    • Posted November 10, 2020 at 10:46 am | Permalink

      Great question. The idea of having a single payer for all healthcare (the government) definitely has its supporters here in the U.S. But it would likely lead to what we see in Canada (the system outside the U.S. I know best), which is untenable wait times for anything other than emergent care, which is all handled by already-burdened ERs. You won’t go broke getting healthcare in Canada like you can in the U.S., but you won’t have appropriate access to healthcare either. The single payer system there has resulted in a dearth of primary care physicians that’s even worse than in the U.S.

      • Jan Looman
        Posted November 10, 2020 at 11:04 am | Permalink

        This idea of “untenable wait times” I think is a bit of a myth.

        I’ve told this story before but On New Years Eve in Costa Rica I dislocated my shoulder. I got home on Canada on January 4th (Saturday) and on Monday called my family doc for an appointment. I saw her Friday and she sent me for an X-ray, which I got the following Thursday. Based on the X-Ray I was sent for a CT scan, which I had on Feb. 2 – I would have had it the previous week but I was away. I also saw an orthopedic specialist on Feb. 4.

        The ortho guy sent me for an MRI which I had on February 8 and I was referred for a surgeon who I would have seen March 23 but for Covid.

        I saw the surgeon on June 19 and had the actual surgery July 17.

        From my point of view I did not experience “interminable waits” and, also from my point of view this was not an emergency. Lucky it was my left shoulder and I’m right handed.

        • Posted November 10, 2020 at 11:37 am | Permalink

          One anecdote like this does not dispel a generalization about non-urgent care. You understand that, right?

          • Silvester Stevens
            Posted November 10, 2020 at 1:37 pm | Permalink

            Jerry, your phrase “I’m also told…” is also carrying a great deal of weight.

            “In Canada, I’m also told, prices are lower, but the country is hemorrhaging doctors because of the low salaries, resulting in a severe doctor shortage and interminable waits for medical care except in emergency situations.”

            Yes, wait times are poor in Canada. Poor wait times are not part and parcel of single payer systems. For instance Sweden has some of the lowest wait times yet has a single payer system.

          • Diana MacPherson
            Posted November 10, 2020 at 1:47 pm | Permalink

            A whole country has stories of wait times that aren’t “untenable”. It’s a myth. If you live in the far north it may be an issue. Not only did I just finish a big part of a project that involves putting doctors and students on rotations so I have familiarity with doctors, but I’m a Canadian who uses the medical system a lot. I have Canadian friends whose families use the medical system a lot. I have elderly parents who use the system a lot. It’s simply not true. Nor is it true that we are hemorrhaging doctors. Doctors make a good amount of money (as evidenced by what I see them driving – just saw my ophthalmologist leave in a Tesla last week).

        • Ullrich Fischer
          Posted November 11, 2020 at 4:26 pm | Permalink

          Wait times vary with the urgency of the issue. My wife and I living in Metro Vancouver, BC, Canada had no problem finding a new primary care doctor when our previous doctor retired a couple of years ago. We have no problem and no huge delays getting in to see him. My wife had a couple of hospital visits recently and was taken in within about half an hour on a non-emergency basis. … another anecdote, but pretty representative of the experience of most Canadians at least in major cities. There is a problem getting doctors to remote outposts, but I suspect that is always going to be a problem where the government doesn’t include a stint as GP in an underserved community as part of the internship required to become a full doctor.

      • Diana MacPherson
        Posted November 10, 2020 at 1:44 pm | Permalink

        What? I’m going to a rheumatologist after waiting 5 months because of lockdown. In comparison, I saw an orthopaedic surgeon in a week during lockdown, I got an MRI during lockdown and waited maybe a month (it was a follow up and non emergency). I get into my GP on the same day. i use the medical system a lot so I’m well familiar with it. I don’t know where you get this “untenable wait time” stuff.

        • Ben Curtis
          Posted November 11, 2020 at 8:03 pm | Permalink

          The untenable wait time stuff reportedly (NPR- last week) comes from U.S insurance companies that devote a lot of resources to harvesting long wait time anecdotes about Canadian health in order to convince Americans not to support a national health system. In any system as big as the Canadian system, there will a few anecdotes, but according to the former insurance company executive interviewed about this, they are not that easy to find. (This is hear-say info, i.e., another anecdote, but you don’t really hear many horror stories from actual Canadians and it seems to become news when you do).

    • Posted November 10, 2020 at 10:51 am | Permalink

      We don’t get all that stuff for free. Firstly, we all pay quite a lot of tax, thousands of GBP per year if we are even moderately well paid. Secondly, a procedure like Jerry’s which would be considered non urgent would probably involve quite a long wait for a slot – like months and in 2020 possibly years because hospitals were/are routinely canceling non urgent surgery due to the pandemic.

      Still, I would much rather have our system than the US one. The taxes we pay are vastly less than US insurance premiums and there’s no copay or deductible and no being bankrupted by medical bills. A couple of years ago I did some research to find out how much our health service costs per capita and how much the US healthcare costs. On average we pay about (or we paid about back then) one third of what Americans pay but there’s nobody who doesn’t have healthcare coverage in the UK.

      If the government’s primary responsibility is to protect its citizens, providing healthcare for all should be its top priority.

      • Randall Schenck
        Posted November 10, 2020 at 11:07 am | Permalink

        You are correct, you do not want to trade what you have for ours. Your system would have to get very bad to come close to this. Now if you are rich in America you can afford it. But most people cannot and even if they get coverage where they work, the cost keeps going up and up. If you lose your job you are screwed. Most jobs do not include health insurance any more. Getting a policy on your own today is really costly. People end up with deductibles that are crazy. Like $5000 deductible before the plan pays anything.

        I worked for a good company that had health insurance but you still had to opt in and pay for it. Group plans they are called. That is how most people are covered today. But again, lose your job and you are toast.

        • amyt
          Posted November 10, 2020 at 6:25 pm | Permalink

          My policy “on my own” was the one I had after 25+ years working for the state. Knee surgery cost me $5k. The other knee is failing but now I’m thinking how much pain can I tolerate before shelling out the $5k??

          • Posted November 12, 2020 at 4:26 am | Permalink

            how much pain can I tolerate before shelling out

            Which is a question that you really shouldn’t have to ask in a modern developed democracy.

            I find it hard to get my head around the fact that many Americans don’t understand how broken their system is and don’t realise that it doesn’t have to be that way. Maybe more of them need failed knees.

            • Posted November 12, 2020 at 9:38 am | Permalink

              This is a long-standing problem with Americans and the flip side of exceptionalism. Many have no idea how people live in other civilized countries. I was born in the UK of English parents but emigrated to the US at the age of five. I always remember kids asking me whether they had bicycles and nylon stockings in England. Granted, these were just kids, but I still get the feeling that many adults here think all other countries are beneath the US in virtually every measure.

      • Posted November 10, 2020 at 11:08 am | Permalink

        Yes, good point- it’s free in the sense of we pool our resources to provide some sort of healthcare for everyone, so that even if you haven’t paid tax, or not paid a lot of it, for whatever reason (poverty, being a student, low paying jobs) you’re entitled to the healthcare nonetheless. Free at the point of use. But yeah, I cannot imagine being bankrupted by healthcare bills, there has to be a better way than the American way in this case.

    • Steve Pollard
      Posted November 10, 2020 at 11:30 am | Permalink

      I would just add that there is a thriving private health sector in the UK. Many people have health insurance, paid either by the individual or their employer; and quite a few just go direct to a private consultant and pay through the nose.

      Such people may get earlier treatment, but it is doubtful whether they actually get better healthcare through going private – not surprisingly, because many NHS specialists have second jobs working in the private sector. Indeed, standards of ancillary care in the private sector may be worse in some cases (although the food is better). And some specialities (dentistry for instance) are almost impossible to find within the NHS.

      But I know which system I prefer. The NHS has looked after my family all our lives and we have had a pretty good service from them across the board.

      • Posted November 10, 2020 at 11:41 am | Permalink

        Hear, hear!

        My grandfather was once seen in a private hospital, because the NHS one was full, or the doctor was at the private place, or something. Anyway, it was an unexpected and gratis view of the other half. They had full menus for the patients and apparently it was much more spacious and cleaner-looking. But if I want good food I’ll go to a restaurant- the NHS is good enough to take care of me medically!

    • infiniteimprobabilit
      Posted November 11, 2020 at 3:37 am | Permalink

      I think the fundamental difference is not NHS vs ‘private’, but a simple legal rule: In a lawsuit in UK, loser generally pays the winner’s costs. In the US, this is not so. Therefore, in the US, there is no deterrent to suing a ‘rich’ target (such as a hospital or a doctor who has insurance) in the hope of a fat settlement since a sympathetic jury will likely chuck a few million your way *even if there is no merit to your case*. Which in turn enables ambulance-chasing contingency-fee lawyers and sends insurance costs soaring.

      cr

      • GBJames
        Posted November 11, 2020 at 7:52 am | Permalink

        I don’t know. I don’t have statistics to back me up (or to counter me) but I think accounting for the shambolic US healthcare system with reference to ambulance chasing lawyers is mostly myth. A common one, sure. It is a central plank in years of efforts by Republican politicians pushing “tort reform”, which really means removal of the average guy’s ability to take legal action against powerful corporate interests. so… /skeptical

        • infiniteimprobabilit
          Posted November 13, 2020 at 3:22 am | Permalink

          There are pros and cons on both sides. Yes people in (non-USAnian) countries do have to consider very carefully the potential liabilities of launching a lawsuit – against anyone. And this does provide a certain measure of protection for businesses (including Big ones) from getting sued frivolously.

          On the other hand, it also provides a very considerable measure of protection for me (as a private person) against being sued by some random visitor who tripped over my front steps and wants me (or my insurance company) to pay them a few millions for pain and suffering. Which helps keep my insurance premiums down.

          cr

          • infiniteimprobabilit
            Posted November 13, 2020 at 3:29 am | Permalink

            I would also add that, in regard to keeping Big Business under control, non-USAnian countries are much more likely to do it by Government regulation (e.g. safety or environmental rules) where – it seems to me – that in the US it often gets left to citizen groups undertaking class-action lawsuits (which is not always the most coherent way to regulate anything).

            cr

  7. Type Logician
    Posted November 10, 2020 at 10:05 am | Permalink

    It’s worth noting that many medically quite advanced countries have way lower costs than the US, and arguably provide care of at least the same quality. Japan is a perfect case in point. See

    https://en.wikipedia.org/wiki/Health_care_system_in_Japan

    for (*lots* of) details.

    • Posted November 10, 2020 at 12:53 pm | Permalink

      Yes, we pay 2X to 3X what the rest of the “developed” world pay. And our outcomes are not better.

      There have to be gate keepers for health care; but they don’t have to get very wealthy doing it (US private insurers).

  8. eheffa
    Posted November 10, 2020 at 10:12 am | Permalink

    That is a rip-off.

    No wonder the establishment medical system is rallying behind Trump to preserve the status quo.

    I am an Anesthesiologist practicing in Canada.
    My fee for this procedure would be a Consultation + time billed for 3.25 hours totaling something like ~ $600.- CAD.

    And yes, that list of drugs administered is quite typical.

  9. Hempenstein
    Posted November 10, 2020 at 10:13 am | Permalink

    I see that you got some of what the anesthesiologist told me that I got for my last colonoscopy (for which they let me stay somewhat awake): Fentanyl!

  10. GBJames
    Posted November 10, 2020 at 10:13 am | Permalink

    They simply aren’t numbers that reflect costs of procedures. Nobody pays this except people who are unable to get decent insurance. Insurance companies don’t pay these charges. And Medicare certainly doesn’t. We need Medicare for all, IMO.

    • Posted November 10, 2020 at 10:16 am | Permalink

      It’s not clear whether those prices are the sticker prices that get discounted, or are the ALREADY-DISCOUNTED prices. I don’t know, and it would be hard to find out, as that would reveal information that’s supposed to be secret (like the percentage discount each insurance company has negotiated).

      • GBJames
        Posted November 10, 2020 at 10:28 am | Permalink

        When the payment is done by your insurance you should get an accounting. I will be amazed beyond amazement if they pay anything like these numbers.

        • Posted November 10, 2020 at 10:51 am | Permalink

          I get one figure, that’s all.

          • GBJames
            Posted November 10, 2020 at 11:02 am | Permalink

            Well you can at least compare that to the total from that horror-show account you just received. From that you can extrapolate.

          • Historian
            Posted November 10, 2020 at 11:19 am | Permalink

            The accounting you received from the hospital is almost certainly the “sticker price,” which is much higher than they will receive from your insurance. I would bet that the hospital and other billers will actually receive no more than a third of the total bill. Yes. The poor slob who has no insurance will be on the hook for the total amount, but if the person is savvy enough, the bill can be negotiated to an amount considerable less.

            When I receive my Explanation of Benefits from my insurance company, I get a breakdown of what the provider charges, the amount the insurance pays, and my co-pay. I have seen rarely providers receiving more than 50% of the nominal charge. I have seen some providers receive no more than 15% of the charge. There must be some sort of accounting or tax gimmick for providers to charge much more than they will actually ultimately receive, although they may hope that they can squeeze a few unfortunates to pay the full amount charged.

            • Jonathan Wallace
              Posted November 11, 2020 at 1:25 pm | Permalink

              I fear that many ‘poor slobs’ may not be savvy enough to negotiate the fees down to an amount considerably less. Being poorly educated or having a low intellectual ability should not be reasons for condemning someone to sub-standard health-care.

      • Randall Schenck
        Posted November 10, 2020 at 10:29 am | Permalink

        I think you will have to wait to see all the statements from medicare and your supplemental insurance. Even then it may be hard to put together. Naturally it goes through medicare first, then on to the insurance company and then they send you a bill for you to pay. It often gets loaded on different statements as well.

        Just as a side note to others – I do not have to pay for my supplemental because the company I worked for pays it after I retired. Nobody gets this kind of thing any more, and my company quit paying it several years ago. I was grandfathered in. If I had to pay the supplemental (me and the wife) it would cost me at least $350 a month and again, this is just supplemental after you go on medicare.

      • Posted November 10, 2020 at 1:35 pm | Permalink

        I am almost certain those prices are NOT what Medicare and your supplemental insurer pay. My supplementary insurance statement indicates the stated prices charged by the provider and the discounted prices paid by each insurer and they are very different. Sometimes the Medicare allowed amount is a fifth or less of the hospital’s stated price. If you want to know what Medicare paid, look at your Medicare statement when it arrives.

        When I total up what my supp pays over the course of the year, it is less than the premium they charge me. I would be ahead if I skipped the supp and paid out of pocket if I could pay their discounted price, but of course I cannot.

        • Diana MacPherson
          Posted November 10, 2020 at 1:54 pm | Permalink

          Yeah most likely not because can you imagine an insurance company paying high costs? They’d incentivize the hospital to lower prices immediately.

  11. Posted November 10, 2020 at 10:23 am | Permalink

    The cost for anesthesia is high because it is the riskiest part of the surgery. Anesthesiologists are the most often sued. When I was in high school, I had a friend whose father went in for routine gall bladder surgery. The anesthesia machine delivered 100 times the proper dose and he died as a result. It evidently happens a lot.

    When people complain about capitalism, what they should be complaining about is its implementation. Success counts on an informed market that can shop for the best value. Government’s role is to ensure that consumers have access to information that allows them to make wise choices. We have the opposite of that in health care. I suspect that blame should be placed on politicians and the medical and insurance lobby that they’re forced to work with. Until this is fixed, we will have relatively bad health care at high prices.

    • eheffa
      Posted November 10, 2020 at 10:44 am | Permalink

      The state of Anesthesia care from your high school days is like comparing a Chevy Chevette to a Tesla. Not the same thing at all.

      Nonetheless, despite much better monitoring & better safety systems, modern good anesthesia care still demands vigilance and expertise.

      • Posted November 10, 2020 at 11:00 am | Permalink

        Sure, the technologies have changed, but the conclusions are still the same, right? Anesthesia still costs a lot because of insurance and that’s high because it is often the cause of bad surgical outcomes. If that’s wrong, do you have some references?

      • JMark
        Posted November 10, 2020 at 11:11 am | Permalink

        Thank you for responding to Paul’s comment. I’m going for a colonoscopy next month and I started getting very nervous!

        As to costs, I live in NJ and received anesthesia for a prostate biology last February. The anesthesiologist charged $1800 but the negotiated insurance cost was $373, of which I was fully responsible for all (high deductible plan)

        • Diana MacPherson
          Posted November 10, 2020 at 1:55 pm | Permalink

          I always like to meet my anesthesiologist just so I for some reason know who is in charge of keeping me alive. 🙂

          • Posted November 10, 2020 at 3:53 pm | Permalink

            Good idea. It also helps him see you as a person and not just another tedious monitoring session. He might be less likely to fall asleep while you’re in La La Land.

            • Diana MacPherson
              Posted November 10, 2020 at 4:06 pm | Permalink

              You usually meet them during pre-op. At least I did when I had my surgery. Then I was sad that the one I met wasn’t the one doing it. Oh well. I couldn’t see them very well in the operating room without my glasses/contacts.

        • Mathew Goldstein
          Posted November 11, 2020 at 6:32 pm | Permalink

          Anesthesia should be optional for a colonoscopy. Colonoscopy is not painful, anesthesia is not needed.

          • ThyroidPlanet
            Posted November 11, 2020 at 7:06 pm | Permalink

            “Colonoscopy is not painful, anesthesia is not needed.”

            How might we describe the week-long preparation, and the state it leaves one in at the moment the colonoscopy begins? During? And when it ends?

            Interestingly enough, If I recall correctly, Daniel Kahneman (sp.?) discussed an experiment in which colonoscopies were conducted and I tjink there were a couple types of anesthesia delivered, and they asked about the patients recall of the procedure. I think it supported the notion of anesthesia-free colonoscopy is perfectly fine… for some….

            • ThyroidPlanet
              Posted November 11, 2020 at 7:08 pm | Permalink

              I think this is the talk : https://www.ted.com/talks/daniel_kahneman_the_riddle_of_experience_vs_memory

              • ThyroidPlanet
                Posted November 11, 2020 at 7:24 pm | Permalink

                OK – just rewatched – nothing about anesthesia. Sorry. He does actually mention an amnesia drug but it’s in a thought experiment.

                BTW – fun WEIT detail : Kahneman refers to a vacation he took in Antarctica.

            • Diana MacPherson
              Posted November 11, 2020 at 8:25 pm | Permalink

              They knock you out but they don’t put you right to sleep like when you get an operation. I woke up during mine. That was unpleasant.

      • Posted November 10, 2020 at 12:58 pm | Permalink

        I agree. I have had surgeries in: ~1973, 1990, 2006, and 2018.

        Every time, the anesthesia got much better (from my perspective, fewer side effects) with much less of a “hangover” each successive time.

        In 2018, I was up and walking around on my new hip within a few minutes of getting to the recovery room.

        • Jonathan Wallace
          Posted November 11, 2020 at 1:30 pm | Permalink

          Hopefully you will not need to find out from direct personal experience whether things have continued to improve since 2018!

    • bill
      Posted November 10, 2020 at 10:44 am | Permalink

      i don’t think the risk of anesthesia drives the cost. i think it is more likely the effect of lobbying and negotiations between the various players. the ama sets rates for medicare, private insurers peg to that, private docs are advised to bill several times the medicare rate to ensure as much income as possible.

      there is a reference to costs in the original price fix; but it is part of a price loop in which higher payments inflate costs down the line, diluting any real connection to costs and permitting corrupt practices.

      • Posted November 10, 2020 at 1:07 pm | Permalink

        It is not the risk of anesthesia that drives the cost. There is a little-known committee in the AMA called the American Medical Association/Specialty Society Relative Value Scale Update Committee, or RUC, that makes recommendations that are pretty much automatically adopted by CMS that sets the reimbursement rates Medicare pays for healthcare, which then determines what private insurers reimburse. Here’s a link: https://khn.org/news/ama-center-public-integrity/.

        • Posted November 10, 2020 at 1:21 pm | Permalink

          Nice but you didn’t give a theory as to why this committee recommends such a high cost for anesthesia. If not risk, then what? I heard reliably decades ago that it was because of risk and its effect on the price of malpractice insurance. If prices are still high but the reason has changed, then it would be interesting to hear the new reason. So far, no one here has suggested one.

          • bill
            Posted November 10, 2020 at 5:04 pm | Permalink

            not sure when and where your info comes from, but the gas-passers are about at the median for today’s liability claims and awards. the surgeons are all higher, as well as oncology, emergency medicine.

            the system codified an existing pricing structure, which grew out of lobbying efforts. it has allowed for some crazy stuff; eye surgeons able to do 30 surgeries a day for big bucks; new scans from expensive machines costing more to read. all strictly legit.

    • Randall Schenck
      Posted November 10, 2020 at 10:51 am | Permalink

      Your comments fit right in with another thing about our system here. The doctors who deliver babies is another one with very high insurance cost. This is because they get sued a whole lot and it really drives up the cost for the doctor. What happens is fewer and fewer doctors get into this business. Most small towns no longer have any doctors who deliver babies. People may have to drive 100 miles to see a doctor.

    • Posted November 10, 2020 at 1:00 pm | Permalink

      “The anesthesia machine delivered 100 times the proper dose and he died as a result. It evidently happens a lot.”

      You probably ought to define “a lot” here.

      “Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.”

      34 deaths per year is way down in the noise. About 30,000 people die from the flu every year.

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697561/#:~:text=Each%20year%20in%20the%20United,in%20the%20elderly%20and%20men.

      • Posted November 10, 2020 at 1:17 pm | Permalink

        That has little to do with my point as to why anesthesia is so expensive. You’re not going to drag me down the rathole of looking at medical statistics. AFAIK, it’s because the anesthesiologist gets sued a lot and, therefore, their malpractice insurance is very high. They must recover that cost, right? Perhaps the anesthesiologists are being overcharged for malpractice insurance.

      • eric
        Posted November 10, 2020 at 2:34 pm | Permalink

        Well you’re missing the number of people who undergo surgeries where this is a relevant risk. 34 is not many if that number is 10,000,000 (surgeries). If it’s 10,000, that’s quite a different issue. I don’t know what that number is. I’m not even sure how to define “relevant surgeries.”

  12. Silvester Stevens
    Posted November 10, 2020 at 10:23 am | Permalink

    “In Canada, I’m also told, prices are lower, but the country is hemorrhaging doctors because of the low salaries, resulting in a severe doctor shortage and interminable waits for medical care except in emergency situations.”

    The Canadian doctor shortage is for the most part due to most doctors (esp specialists) being boomers and retiring.
    The Fraser Institute, a right wing think tank puts the blame on lack of training new doctors.
    Canada is not “hemorrhaging” doctors. The biggest shortage is in high cost of living cities and tiny remote towns. Most don’t want to live the latter (even with significant signing bonus in salary increases) and young doctors don’t want to pay high costs of living while paying off student loans.

    Waiting times are currently high because of cancelled surgeries due to Covid-19. Otherwise wait lists are generally pretty reasonable. Wait times for elective surgery is higher.

    For many Americans the wait time is infinite. Since they don’t have health care insurance and can’t afford to pay, they die while waiting.

    Canadians don’t see fundraisers for children or parents selling everything they have to get life saving treatment.

    A study by the University of North Carolina showed 25% of cancer patients in the USA can’t afford treatment.

    While Americans who can’t afford to pay supposedly can get emergency treatment in the ER, this only covers stabilizing and the prevention of immediate loss of life and limb. If they have a chronic condition and they aren’t going to die today, or their inability to afford insulin is costing them their legs, that is just too bad for them.

    A Harvard study concluded 45,000 Americans die every year from lack of affordable health care. I wonder how many Americans live in poverty because they are stuck in a vicious loop, being unable to afford proper medical care to manage or cure chronic health conditions and due to chronic health issues, being unable to work, or work enough to afford health care.

    American doctors surveyed for satisfaction report second to lowest levels in industrialized countries.
    Canadian doctors moving south peaked in the 90’s and is much lower now.
    Doctors also move in the other direction, American doctors move to Canada to practice.

    https://www.washingtonpost.com/blogs/wonkblog/post/meme-busting-doctors-are-all-leaving-canada-to-practice-in-the-us/2011/06/03/AGVdAuHH_blog.html

    • Posted November 10, 2020 at 10:51 am | Permalink

      What’s the reason for the lack of training new doctors in Canada? I suspect it’s because primary care everywhere is now viewed as a terrible field and the reimbursement in Canada for primary care is at least as bad as it is here in the U.S. My wife’s mother is demented living in Canada and her biggest obstacle is getting her acute care. Every clinic she called to get her mother in had a voicemail message (no live person ever answered) that literally said that if anyone left a message twice, they would not have their call returned. Call back times were listed in terms of weeks. The wait times in Canada are far worse than they are here in the U.S.

      • Silvester Stevens
        Posted November 10, 2020 at 1:15 pm | Permalink

        The lack of training was a lack of spots in medical schools and the long time period it takes for new doctors to reach the point of being allowed to practice medicine, especially specialists. The number of spots were increased. It was a case of doctors retiring faster than could be filled. As pointed out in a second comment, this problem is being seen in the US as well and is getting worse.

        Yes, wait times are longer than in the US, but I will reiterate, except for those in the US who can’t afford to pay whose wait times are infinite.

      • Silvester Stevens
        Posted November 10, 2020 at 2:09 pm | Permalink

        “Philpott said family physicians, pediatricians and psychiatrists can make $100 000 more annually in Canada, on average, compared to the US.”

        “According to data from the Canadian Medical Association, the number of US-trained physicians working in Canada grew less than 3% from 1996 to 2005 (up from 493 to 506), but jumped 42% from 2006 to 2014 (508 to 721).”

        One of the major advantages in Canada is doctors require significantly fewer support staff for billing purposes and dealing with insurance companies, by as much of a factor of 5. American doctors can see a 30 percent refusal rate in claims which then must be billed to the patient which may be paid, go to a collections agency or be forgiven.

        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119158/

        It’s an interesting paper that highlights some of the advantages and problems US doctors in Canada face. One of the problems the paper cites is licensing hurdles facing US doctors and the requirement to have a job before moving. The licensing hurdles are set by the provinces colleges of physicians which are separate (professional) entities that are reluctant to change their requirements for immigrant doctors from the US even though the education and licensing standards are largely the same.

        BTW, I found several studies showing average wait times to see a physician in the US is high and jumped dramatically after 2016.
        In Boston average wait times to see a doctor was 60 days.
        Like Canada wait times vary by region (state vs province), urban vs rural and a lot depends on the cost of living in the area.

        The issues are considerately more complicated than Canadian doctors aren’t getting enough compensation and isn’t even necessarily true.

        • Diana MacPherson
          Posted November 10, 2020 at 2:22 pm | Permalink

          I often call the Colleges of Physicians and Surgeons “Doctor Club”. I’m sure it isn’t as bad as I snarkily remark but they do throw up barriers to foreign trained doctors. I think they are better now maybe because they were criticized for this.

      • Diana MacPherson
        Posted November 10, 2020 at 2:10 pm | Permalink

        LTC in Canada is bad. Most of it has been privatized so if you have the money you can get care. If you don’t, well get in line. It’s horribly underfunded. I hope with the COVID crisis which revealed such incompetence in private LTC that the military in Ontario and Quebec were called in to help, finally gets the attention of politicians (military were required to report what they saw up their chain of command and reports were written).

        • Posted November 10, 2020 at 2:50 pm | Permalink

          What I want to know is that if everything is peachy keen with government medical care in Canada, why are there ANY private physicians?

          • Diana MacPherson
            Posted November 10, 2020 at 4:12 pm | Permalink

            Huh? What private physicians? There are private health care facilities for long term care but private physicians are not something many Canadians have heard of. And the private LTC is a complete gong show in Ontario, well at least some are. The Ontario government and the feds have committed to solving the terrible lack of funding that went into LTC. So are you referring to actual private physicians or the privatization of LTC?

    • steve oberski
      Posted November 10, 2020 at 10:58 am | Permalink

      In Canada,…

      All anecdotal, but my experience and that of immediate family, belie that statement.

      Recent non emergency interactions with the Canadian medical system include:

      – 2 intraocular lens replacement procedures for cataracts, all covered by OHIP (Ontario Heath Insurance Plan) except for the upgrade to non standard lens and some post-operative medication. My out of pocket costs, picked up by my employer extended medical plan was on the order of $200.

      – Heart valve replacement for parent.

      – Upcoming (this month) hip replacement for parent.

      None of these procedures involved any excessive wait time, referrals to relevant specialists happened within the stated wait times.

    • Silvester Stevens
      Posted November 10, 2020 at 11:01 am | Permalink

      A quick search reveals the USA is also facing a doctor shortage.

      It’s probably hidden and/or offset by the number of people who don’t go to the doctor because they can’t afford to pay. (Which also points to the problem of American healthcare being the most costly in the world but treating a significantly smaller portion of the population)
      It’s also hidden by the number of people who go to urgent care centers.

      The articles state the reasons are largely the same as Canada, boomer doctors reaching retirement age.

      There is expected to be a lag between the time it takes for doctors to be trained and fill retiring positions, it’s expected to peak in a decade.

      Covid-19 could exasperate the problem in both countries due to lost training times and loss of doctors to burn out and death.

      I expect death for doctors (and other health care workers) will be a larger problem in the US as Covid-19 is expanding exponentially out of control.

      On a side note, Canadians aren’t paying for Covid-19 tests. I see the cost varies wildly in the US. I wonder how many Americans are not getting tested because they can’t afford it?

    • Peter
      Posted November 10, 2020 at 11:30 am | Permalink

      For the past 15 years my wife and I have lived in a small (43,000) city on the Canadian prairies. The local health centre serves a regional population of approximately 150,000. We have access to some of the best care I have experienced; wait times for surgery (cataracts, gall bladder, rotator cuff, hernia) have been reasonable, and never more than a few months. How long would you think is reasonable to wait for cataract removal and intraocular lens replacement – a month, two months?

      I can get an appointment with my primary care physician or attend one of numerous walk-in clinics. The physicians in those clinics have access to my medical records. In fact it was a doctor in a walk-in clinic who ordered blood work based on symptoms I was experiencing and correctly diagnosed type 2 diabetes. The blood work and a follow up appointment happened the same day.

      Canadian health care is not without issues; costs are increasing and the population is aging, but the quality of care is exceptional.

      • Posted November 10, 2020 at 1:03 pm | Permalink

        Every single Canadian I know well has retained their Canadian citizenship — explicitly for access to Canada’s Medicare!

      • Diana MacPherson
        Posted November 10, 2020 at 2:12 pm | Permalink

        And I have to say the work the provinces do with hospitals is outstanding in resourcing small communities. In a private system I just don’t see sparsely populated Canadian cities being taken care of because there would be no profit to be had there and costs would be much higher. Working with people who administer the education of physicians I’m really impressed by their dedication.

    • Diana MacPherson
      Posted November 10, 2020 at 2:02 pm | Permalink

      I work in the Education department of a university with a network of hospitals. I just don’t think there is a shortage of Canadian trained doctors. My university’s hospital, run by the Faculty of Health science actually invented the processes adopted around the world in medical schools – it was my university that invented problem based learning, and the MMI for admitting medical students. It’s a very popular medical school that attracts students from around the world. It’s highly competitive and each year thousands of applicants are reduced to hundreds. It churns out doctors galore and they are placed in clinical rotations all over the province. There are many incentives to stay in Canada as a doctor. I don’t see the shortages people talk about. The biggest risk is rural communities just as they are short for everything especially in the far north with extremely low populations. Still, the health care system and the rotations programs in many universities make sure that learners are placed there to ensure that access to medical care is available.

      • Posted November 10, 2020 at 3:00 pm | Permalink

        It this just dead wrong, then?

        https://www.fraserinstitute.org/article/canadas-doctor-shortage-will-only-worsen-in-the-coming-decade#:~:text=For%20many%20years%2C%20physician%20training,on%20medical%20training%20in%20Canada.

        Over the next decade, the physician shortage will become more severe. Even if government imposed restrictions on the number of doctors being trained in Canada are immediately removed, it won’t have an impact for much of the next decade given the time it takes to train a new doctor. The only short-term solution is to recruit more foreign-trained doctors.

        In 2006, the most recent year for which data is available, Canada’s physician-to-population ratio (age-adjusted) ranked 26th among 28 developed nations that maintain universal access health care. It’s not surprising then that some 6.6 per cent of Canadians reported being unable to find a family doctor in 2010. Canada’s physicians are unable to meet the demand for health care services because there are simply too few of them.

        And from the CBC: https://www.cbc.ca/news/canada/british-columbia/bc-doctor-shortage-medical-fees-1.4100251

        There does seem to be a shortage of family physicians in Canada; I found a ton of articles stating this.

        • Diana MacPherson
          Posted November 10, 2020 at 3:03 pm | Permalink

          I think they are projecting shortages for family doctors in particular but predicting a shortage of family doctors is a long way from saying Canadians just can’t get medical attention in a timely manner partly because there are no doctors to help. Canada actually uses a lot of Saudi and Gulf State doctors who are trained here but mostly they aren’t going into practice here because they have to go back to Saudi or the Gulf States or their governments cut off their funding. This was evident when Saudi got angry at Canada for remarks the (now) deputy Prime Minister made about human rights and recalled their doctors from here. I know we are absolutely churning out doctors. For someone to say that we aren’t educating doctors here is just false.

        • Diana MacPherson
          Posted November 10, 2020 at 3:07 pm | Permalink

          And I should mention that one article is specific to BC. Remember that Canada’s health care is managed at the provincial level with oversight of funds at the federal.

        • Raskos
          Posted November 10, 2020 at 8:53 pm | Permalink

          I wouldn’t pay any attention to anything published by the Fraser Institute. It’s a right-wing belief tank (partially funded by the Kochs)and anything that comes out of it relevant to the Canadian medical system is a run-up for a call for privatized medicine here.

  13. peter alexander
    Posted November 10, 2020 at 10:27 am | Permalink

    Three years ago I had a total hip replacement (THR) operation.

    It was farmed out by the NHS to a private hospital, who charged around $14,000.

    THR is major surgery. It scares me to think what it might have cost in the States.

    As you say, Jerry, your healthcare system is utterly broken. Profit maximisation and medical treatment are manifestly incongruent objectives.

  14. denise
    Posted November 10, 2020 at 10:27 am | Permalink

    I have to sign something before any procedure saying that I will pay any charges that Medicare won’t pay. I tried to hand-write that I didn’t want to receive any services from providers who don’t take Medicare unless I consented first, but the hospital will not allow this.

    There was a story a while back about a patient billed $150k from an out-of-network assistant surgeon hired by the in-network surgeon without the patient’s knowledge. Go to sleep thinking your insurance will pay, wake up owing $150k. It’s terrifying. And hard to believe that it could be legal, but it is.

    • EdwardM
      Posted November 10, 2020 at 10:40 am | Permalink

      When my son was eight weeks old he got an RSV infection that resulted in a hospital stay which cost more than $180,000 dollars. The insurance company refused to pay. The reason? His pediatrician hadn’t signed off on him being admitted to the hospital . Fortunately my neighbor at the time was lawyer. Did I say lawyer? She was more an attack dog. It took a lot of angry correspondence and threats but eventually the insurance company caved.

      This is health care in America. I was lucky to have my neighbor. I have no hopes that it will improve. None. I no longer see doctors except for emergencies, as I face a situation many American must confront – if I get sick, I’ll lose my job and if I lose my job I won’t be able to pay for my care. So I only go if I’m bleeding bad enough to need stitches or have a bone that needs setting.

      • Posted November 10, 2020 at 1:08 pm | Permalink

        May I ask what you do for your job?

        That sounds dire and I am sorry for you.

        My experience is diametrically opposite: My company covers me (no direct cost to myself) with short-term disability: It paid me 100% of my salary while I was out for 6 weeks due to: Shingles (get your shingles vaccination! You do NOT want to get shingles — forget the pain, it causes permanent nerve damage, which I live with now), concussion, stroke (the neurologist suspects this was related to shingles), hyponatremia, and post-herpetic neuralgia. Yes, I know I am lucky.

        My bills for that year (including three ambulance trips to the hospital) was about $90,000. I only had to pay about $4500.

  15. Dave B
    Posted November 10, 2020 at 10:27 am | Permalink

    Had major abdominal surgery back in 2016 – hot appendix, hole in my large intestine, removal of about a foot of my small intestine, transection of small and large intestine, 3 weeks of post op care. Net bill – zero.

    Canadian heath care, oh so bad, according to repiglican and some Canadian conservative sources.

    • bill
      Posted November 10, 2020 at 10:53 am | Permalink

      the bill is only zero if you disregard the portion of your tax which funded the system. but even that is lower than the u.s., by about half.

      unknown, and perhaps unknowable but real, is the amount canadian and other systems are subsidized by the u.s. system. how much would drug firms charge you if the u.s. refused to pay more than the cheapest international price for a drug is unknown; but there’s little doubt that cost-shifting like this is a thing.

  16. bill
    Posted November 10, 2020 at 10:29 am | Permalink

    your numbers on your bill are meaningless; at least they in no way reflect the cost of the items or professional services.

    they are the droppings of a corrupt market which operates opaquely.

    there is no market in health care services at the consumer purchase point. a free market does not apply to consumers in health care, for several reasons; consumers lack the expertise required to know what they want and need, they are not able to ‘walk away’ in many situations from a deal. the massive interventions sometimes required in medicine will be so costly in time, materials and expertise that the vast majority of consumers cannot bear them, requiring insurance.

    insurance destroys markets, transmuting them into markets for insurance.

    in my opinion, insurance should be nationalized. other than advances in who best to exclude from a business perspective, it basically aggregates funds and pays bills. competition brings little innovation; our large national experiment suggests it increases costs.

    the power of the medical insurance industry to shape care is huge. this power needs significant regulation.

    our fee for service/private insurance system has been gamed to fund specialties who gain from procedures significantly more than primary care gatekeepers. this is upside down. if we incentivize and develop primary care into real managers of care and move consultants into a consulting role costs would improve.

  17. KD33
    Posted November 10, 2020 at 10:34 am | Permalink

    Dr. Lickerman – thank you for taking these questions. I had an ultrasound scan a few years ago. The bill was ~ $970, about $250 of which I had to pay out of pocket. But if I walked in with no insurance, I’d have been charged only ~$500. So insurance only saved me ~50%. There was similar “cash price” difference numbers for a colonoscopy. My question: why is the total bill so much higher when insurance is involved? (The “overhead” of insurance admin does not seem to account for the difference.) Is this “cash price” difference typical or systemic?

    • Posted November 10, 2020 at 1:22 pm | Permalink

      Great question! The answer is, many providers will charge a lower cash pay price because payment is immediate. The bill is higher when insurance is involved because providers create a “chargemaster” which has prices that are like an MSRP when you’re buying a car. It represents a ceiling price–an initial price–in a negotiation that almost no one pays. Providers inflate their chargemaster prices because they know they’ll be forced to negotiate different discounts with insurers. So while private insurers get maybe a 50% discount off chargemaster rates, Medicaid takes maybe a 90% discount (which is why most medical systems consider Medicaid to be “bad” insurance: it reimburses them for a given service at the lowest rate). This is why, paradoxically, if you’re uninsured, you may pay more than even large insurance companies. For reasons that defy logic, medical systems will sometimes quote the uninsured their chargemaster rates–the highest price–rather than a true cash pay rate.

      If you’re getting care from a small provider (vs. a large hospital system), you’re much more likely to find a reasonable cash pay rate that ends up being cheaper than going through your insurance (depends on your yearly out-of-pocket max and how far into it you’ve already spent).

      Large hospital systems likely raise their chargemaster rates to meet revenue targets. Contrary to what you’d expect, insurers are happy to pay these rates because it enables them to increase premiums, which they want to increase because Obamacare imposed a medical loss ratio of 20% on most insurance plans. That means insurers must spend 80% of their revenues (premiums) on healthcare claims. If you’re limited to only 20% of the pie to make profits, what do you do? Find a way to make the pie bigger so that the absolute dollar amounts you bring in goes up. This is what the insurers have done, and it’s why premiums have gone through the roof since Obamacare was enacted. The unit cost of most medical care has increased mostly with inflation. Healthcare prices set by providers have increased by far more.

      • Mathew
        Posted November 11, 2020 at 6:54 pm | Permalink

        Interesting. This appears to imply that nationalizing health insurance has at least the potential to be more efficient than ACA can be.

  18. Alexander
    Posted November 10, 2020 at 10:34 am | Permalink

    Holy Moly! Three years ago I had a triple-bypass operation and a valve replacement, and combined with complications before the operation, I spent five weeks in hospital. I don’t know what the complete bill was, but I paid perhaps a few hundred dollars out of my pocket. And my insurance bill here in Belgium, including hospitalization, is a few hundreds of dollars per year. I think the medical situation in the US, being a business, is completely absurd.

    By the way, when I lived in Naples, Italy, where my wife had a knee replacement at the University Hospital, we never saw a bill. But we saw Americans that flew over to get knee replacements.

    • EdwardM
      Posted November 10, 2020 at 10:50 am | Permalink

      My brother in law had a triple by-pass two years ago which resulted in him missing more than two months of work. That meant they couldn’t pay their mortgage as he wasn’t working. The US doesn’t have any medical leave laws so it’s up to the employer if it’s a benefit or not. It wasn’t for my BinL. He’s unemployed now and, being 61 years old its unlikely he’ll find another. My sister found a job, so they can still live indoors, though there is now no way that she can retire.

      This is America.

    • Posted November 10, 2020 at 1:11 pm | Permalink

      You are pointing out a lot of cost-sharing by your fellow citizens there. And I wonder if you are fully accounting for the tax costs that are directed to the health system?

      Regardless, I regard the European (and UK, CA, NZ, AU) systems as much superior to the US system.

  19. Posted November 10, 2020 at 10:37 am | Permalink

    I’ve said for years that the healthcare system is, at best, a Rube Goldberg machine, with most adjustments just being local Band-Aids applied to places where the mechanism it teetering most noticeably. I don’t see how anything short of a full collapse–a metaphorical Chicxulub asteroid, wiping it all out and leading to a complete restart of the system–will provide for major changes.

    But even that is unlikely to produce a perfect, or even quasi-optimal, system, because there probably IS no perfect system, and there are so many competing pressures and forces that it’s difficult even to see where the optima would be. The phase space is just too big and difficult to chart. We can’t even get the LEGAL system working close to efficiently, and WE designed that from the ground up. Medical care involves trying to find ways to fix and adjust and optimize the health and the care of the human body (which, when you include the brain, makes it the most complicated thing in the known universe), which we understand only incompletely, and in which every time you push down in one place, at least one other spot pops up. And the economics of the situation behaves similarly.

    Frankly, it’s a miracle that it works as well as it does. Maybe the Band-Aids aren’t such a laughable thing after all. And certainly, there’s no reason not to keep trying to seek solutions…but we don’t even have consistent measurements, decided in advance, about how to gauge the success or failure of any given experiment in healthcare management.

    Eliezer Yudkowsky discusses just some of the problems–and what SEEM at least like logical, better ways to run things–in his book, “Inadequate Equilibria”, and many of his ideas are good (as usual), but there’s not going to be any simple solution to optimizing healthcare.

    That said…the fact that people don’t have access to the success and failure rates of their hospitals, doctors, etc., is ridiculous. Online rating services, which at least try to address some of this, are mainly popularity contests, and a bad personality makes a doctor much more likely to be sued than does simple incompetence. But laypeople don’t even really know HOW to rate their physicians and hospitals and other healthcare providers. The internet just creates an even lower signal-to-noise ratio for people to try to navigate.

    I’m not pessimistic. I’m not. Really. And I’m also not in denial about being pessimistic.

  20. bill
    Posted November 10, 2020 at 10:47 am | Permalink

    here’s the big unknown; how much does our obscene profit from medical science in our corrupt system drive the incredible innovation around the world? we’re sort of the goose and the golden egg. when the u.s. purges itself of these profits, what happens to advances in medicine?

    • darrelle
      Posted November 10, 2020 at 12:24 pm | Permalink

      I don’t think the premise survives scrutiny very well. For one, the US became innovative in medical science long before health care became so unreasonably expensive. Too, many other countries are very innovative in the medical sciences. And all of those countries have some kind of medical care for all, all of them at a fraction of the cost of the US, and nearly all of them with medical outcomes as good or better than the US.

      A large amount of those huge profits go to parts of the system that range from entirely unnecessary to bloated beyond any reasonable need. Like insurance companies. The system is thoroughly gamed and is the opposite of a fair and free market.

      This argument that the US system being so shitty to its own people is worth it because it allows medical innovation that is the savior of the whole world has never been true and needs to die. I mean, if we are the greatest, richest country on Earth why can’t we be the best at medical innovation, costs and outcomes all at the same time?

      • bill
        Posted November 10, 2020 at 1:34 pm | Permalink

        i think you’ll find about half of medical research articles originate in the u.s.

        and i think that while most large medical corporations are multi-national, they and wholly foreign corporations make much more profit in the u.s. market.

        to what extent the reduced cost of other countries’ expense, particularly pharmaceutical expense is subsidized by excessive profits in the u.s. is uncertain; but that this dynamic occurs is not. when stryker can no longer charge 16K for a hip prosthesis here, and 1K in switzerland, they likely will not keep current pricing structure. they’ll try to make up lost revenue. this applies to a lot of stuff.

        your closing premise, that we are the greatest country, requires a definition of greatest. we are not the richest.

        i’ve not seen data which would allow this notion to die; history supplies reason to wonder to what extent it is valid.

  21. dd
    Posted November 10, 2020 at 10:59 am | Permalink

    Insurance will pay a fraction of the sticker price…maybe $15,000 or $20,000?

    But if you had no insurance, you would get hit with those high prices.

  22. Posted November 10, 2020 at 11:00 am | Permalink

    A few months back I had an emergency health problem erupt. In its wake, I felt frustrated and confounded by the almost complete absence of protections for healthcare consumers. As our host points out, there’s no way to shop around for the best rate, as you could in almost every other market. This problem is especially acute for emergency treatment. It’s either acquiesce to whatever convoluted black box of accounting funds the hospital or get sicker and (depending on the severity of the issue) die.

    I’m alive and healthy today, which is cool, but it cost me. For instance, I was billed about 12400% above over-the-counter rates for common drugs and charged ~$3300 for a bed. The hospital thus far refuses to explain the underlying costs that account for the charges, something any business ought to be willing and able to do if pressed. Better still, the hospital’s billing schedule——apparently unalterable——demands I pay at a rate I can’t afford. At a time when 40% of Americans can’t afford a one-off charge of $400, the hospital wants me to pay a minimum——tacitly agreed to, albeit under duress, when I accepted care——substantially in excess of that number, and which my salary can’t carry. Their advice: let it go to collections.

    I really have no idea how to go about solving these problems, but our current method for funding healthcare strikes me as grossly callous and unsavory, frequently unethical, and clearly unsustainable.

    • Historian
      Posted November 10, 2020 at 11:22 am | Permalink

      Did you qualify for Obamacare (now being challenged in the Supreme Court)? If so, why didn’t you sign up?

      • Posted November 10, 2020 at 11:54 am | Permalink

        I have employer-based health insurance.

      • Posted November 10, 2020 at 11:59 am | Permalink

        It’s a small sample to go off, but when I’ve worked for a public outfit (state universities), my employer-based insurance coverage is excellent. When I work for a private company, as both me and my wife do now, it is notably shoddy.

  23. Bjørn Ove Sætre
    Posted November 10, 2020 at 11:02 am | Permalink

    As a Norwegian living in a society with universal healthcare and other free goodies I am still shocked, but not surprised when hearing the absurd health care system in USA.
    Of course, I know that some Americans think I live in a socialist horror state……….but for the sake of comparison: let’s compare to another country without a welfare state

    Colombia; in 2002 I lived one year in Medellin and had to go the hospital for a cholecystectomy , removal of gallbladder. I was rushed to one of the best and most expensive private hospital in Medellein

    https://en.wikipedia.org/wiki/Pablo_Tob%C3%B3n_Uribe_Hospital
    I was there two full days, private room, excellent care and surgery done with top modern equipment. My travel insurance paid all. The total sum around 1300-1400 US dollar
    Now; it’s almost 20 years ago, but still…….

    My wife, living in Norway with me, but still a Colombian citizen , still pay insurance to a private insurance in Colombia, because that also cover her parents, in addition to herself

    https://www.epssanitas.com/usuarios/web/nuevo-portal-eps#gsc.tab=0
    She just told me she pays around the equaling of 35 US dollar per. month, for herself and her parents……..It’s true. If she need to go to the doctor, she pays a symbolic sums (less than 1 dollar) for each visit. Most drugs are also free or very cheap on this plan
    Now, In Norway my total tax is around 30%, but that includes pension, unlimited free healthcare, social security until I die, free universities and much more goodies

    USA: The greatest country in The World? ……..I think not………….

    (Not my intention to insult Americans, which I consoder very friendly people)

    • Alexander
      Posted November 10, 2020 at 11:51 am | Permalink

      (Not my intention to insult Americans, which I consoder very friendly people)

      Idem here. My wife is American, and I lived about 11 years in the US. We were always insured via my work, but once when I had a flu, my employer wanted a medical certificate, but I didn’t succeed in getting an appointment with a doctor. The only time I saw the inside of a hospital was when I accompanied my NY neighbor on a visit with Holly Woodlawn who landed in hospital after a suicide attempt.

    • Bjørn Ove Sætre
      Posted November 10, 2020 at 11:52 am | Permalink

      Some update about healthcare in Colombia:

      My father in law, a farmer living in his finca, have had bad respiatory symtoms. he called the doc in the village, a team came to his farm, took a covid test, and left again. Just now my wife told me, her father negative for covid and the whole thing was free of charge, paid for the insurance my wife pays for him (again, 35 US per. month)

  24. daniaq
    Posted November 10, 2020 at 11:03 am | Permalink

    That is absurd…
    I would be really interested to hear about what your doctor think is the solution to this problem.

    • Posted November 10, 2020 at 1:27 pm | Permalink

      Aha! There ARE solutions that are already being enacted around the country. For anyone who’s interested, I’d point you here: https://healthrosetta.org/.

      This is why I left academic medicine to found a direct primary care medical practice. I believe the direct primary care model is the answer to fixing primary care. And while fixing primary care won’t fix the entire healthcare system, it will fix a large part of it.

  25. Posted November 10, 2020 at 11:09 am | Permalink

    It sounds like the hospitals and insurance companies are trapped in a vicious cycle of spiraling prices that has nothing to do with real value. Basically, they are moving large amounts of money in a circle and anyone who can skims off a salary or a fee. I’m pretty sure the “actual” necessary cost of materials and labor for a few hours of surgery should be no more than a few thousand dollars. I could be wrnog.

  26. Monika
    Posted November 10, 2020 at 11:10 am | Permalink

    WOW, health care in Germany has its problems, but the US system sure seems f*cked up. We pay around 15% from our wages/salaries, max. 10€ per prescription, 10€ per day in hospital, max. for 28 days.
    If you want you can switch over to private insurance, which is more expensive, esp. for older people, but gets you preferential treatment.

  27. Jon Gallant
    Posted November 10, 2020 at 11:25 am | Permalink

    The Netherlands and Switzerland, in which healthcare is generally well-regarded, have systems based on universal insurance, partly government subsidized. My understanding is that the insurance business in these nations is then viewed as a natural monopoly and is heavily regulated. The US has state-by-state regulation of the insurance business, which of course varies a great deal in stringency.

    A survey of healthcare systems is at: https://en.wikipedia.org/wiki/Health_care_systems_by_country . In the category of “non-universal insurance”, we find the USA along with such other advanced societies as Burundi, Bangladesh, Nigeria, Paraguay, Uganda, the United Arab Emirates, and Yemen.

    • daniaq
      Posted November 10, 2020 at 11:42 am | Permalink

      Haha that is very interesting! That is why it is so shocking to me, a country like the United State being so behind in healthcare…
      embarrassing

      • EdwardM
        Posted November 10, 2020 at 12:19 pm | Permalink

        It is not behind in medical care – for those who can afford it. If you can cough up the dough, medical care here is as good as anywhere and in many cases better.

        The reason we are in such company in terms of our overall heath system isn’t the quality of care; it’s mostly because of issues with access. That is almost entirely driven by how much it costs. We do have a lot of stupid people and we eat so very poorly, so there are cultural reasons for poor health outcomes too.

  28. DrBrydon
    Posted November 10, 2020 at 11:30 am | Permalink

    I agree that there needs to be more price transparency. I’ve always thought that one of the problems with the “Affordable Care Act” is that it didn’t address costs, it just tried to give everyone insurance, which only papers over the problem (apparently literally).

    @Dr. Lickerman, thanks for answering questions. Is it correct that medical students can also get unlimited loans for med school? I would think that in itself would be inflationary for health costs, since there is no reason med schools can’t charge anything they want, regardless of costs.

    • Posted November 10, 2020 at 1:28 pm | Permalink

      If by “unlimited loans” you mean can they borrow the entire cost of tuition, I believe that’s true. And that it almost certainly does contribute to the meteoric rise of the cost of going to med school, which is an entirely separate and desperate problem.

  29. Posted November 10, 2020 at 11:34 am | Permalink

    Wow. I got a load of dental work done here in Germany. Mostly minor things but being the wuss I am I opted to be put asleep for the procedures. I was under for just short of 2 hours. As I opted for this rather than having it perscribed, I had to pay for it myself.

    2 Hours of anesthetic with the anaesthesiologist sitting there monitoring me the whole time? 55 Euro.

    If they had wanted 9680 dollars for it, I would have downed a decent whisky and screamed “Bring on the pain!”.

  30. Historian
    Posted November 10, 2020 at 11:39 am | Permalink

    For those people that are fortunate enough to have a choice in health plans (such as federal government workers), it really is worth the time to study in-depth for each policy exactly what are the out-of-pocket costs for various procedures (co-pays and deductibles), what medical conditions are excluded from coverage, how out-of-network providers are treated and what procedures require pre-approval from the insurance company. Insurance policies differ widely in cost, but equally important, what they cover. The upfront premiums should not be the sole determinant in choosing a policy.

    • Randall Schenck
      Posted November 10, 2020 at 12:01 pm | Permalink

      You are absolutely correct on that issue. I worked for the govt. in a way, DOD nonappropriated but they kind of go the same way. The insurance plan has lots of options and can depend on where you are located. There is a lot of stuff to look at in making a choice. It was not this way when I first started but as cost went up they had to join the group insurance club, and began offering lots of different plans. How much you paid each pay day depended on the plan you choose. After retirement your options tended to go down. My plan became the supplemental when medicare kicked in at 65.

  31. ThyroidPlanet
    Posted November 10, 2020 at 11:42 am | Permalink

    I’m overwhelmed with questions, but I suppose I might ask where on the scale of surgeries this example is – representative or unusual, highly specific or subject to many variations?

    Also how bespoke is the anesthesia – because I know that is almost like a separate process in and of itself.

  32. eric
    Posted November 10, 2020 at 11:43 am | Permalink

    Why are prices so high? Because there is no incentive for doctors and hospitals not to raise prices

    I lean a bit more charitably; I think our health care system is caught in something like a bunch of connected vicious cycles, where doctors have to charge a lot because they have big medical school bills and insurance rates. But medical school charge a lot because they know prospective doctors will make a lot of money. Round and round it goes. Meanwhile, costs for insurance and many other medical add-ons are very high because the community is extremely risk-averse, but that’s because our litigious society is extremely risk-punishing, because lawyers see wealthy doctors as deep pockets. Again, round and round it goes.

    While I certainly don’t see single payer as a silver bullet, I think it can tamp down on these cycles through government regulation. More government medical jobs on non-stratospheric pay scales means medical schools will need to lower or negotiate costs, because otherwise they won’t attract students. Having government (and government lawyers) on the other side of litigation makes private insurance for doctors far less necessary, reducing their cost of living and so lowering their requirement for higher pay (to achieve the same standard of living). It will likely also reduce the size of civil suits and payouts, which in turn will lower insurance rates for those medical areas where it’s still needed. And having medicare having more negotiation power will likely lower what companies can charge.

    In short, all the standard observations about unfettered markets vs. regulated ones. The regulation helps reduce booms, busts, runaway effects, “arms races” between different market components, things like that. All of which we seem to be seeing in the US medical system.

  33. Geoff Toscano
    Posted November 10, 2020 at 11:50 am | Permalink

    Good grief, I really cannot believe these costs! $513 for a Covid test? Considering the numbers that are being carried out daily the ‘normal’ cost must surely be lower?

    I was diagnosed with bowel cancer last year (UK). Starting at the point at which I received notification of an abnormal screening, following a routine submission, within six weeks I’d had a colonoscopy, CT scan, consultations, been operated and discharged. I had six months of (probably unnecessary) oral chemotherapy, with attaching follow ups, blood tests etc. Total cost…estimated £20 for car parking charges, plus fuel getting to hospital! To be fair, I think things would have been very different this year, given the pandemic.

    • David
      Posted November 10, 2020 at 2:22 pm | Permalink

      Regarding your comment about the situation in the UK during the pandemic. In September I suffered with an abcess under my arm. Antibiotics did not resolve the situation so I was referred to my local hospital – the next day I had an operation under general anaesthetic to remove it at no cost to myself. I count myself very fortunate to be living in NHS land and to have had such prompt treatment

  34. Posted November 10, 2020 at 11:53 am | Permalink

    I had an identical surgery (stomach hernia) here in France, and the bill was under a thousand dollars of which I paid a third of that. The French Health Service is often rated the best in the world… But here’s the thing…The American News-Media seem intent upon keeping your population in ignorance about how things work in other countries.
    Vested interests trick people into calling it ‘Socialised Medicine’ but you do not call it Socialised Schools, or Socialised Military, or Socialised Interstate Hiways. I think that Democrats should make a fuss and demand a healthcare system enjoyed by fifty top countries on the world. American Healthcare covers only 80% of the population and costs 18% of GDP. Socialised healthcare costs about 10% of GDP.
    Finally, I am suspicious of all those drugs and procedures listed above. I had NO followup medication and recovered very quickly (aged 75)

    • Posted November 10, 2020 at 11:55 am | Permalink

      I had no followup medication except that they recommended that I take Tylenol. The drugs above were all used before or during surgery.

    • Posted November 10, 2020 at 1:33 pm | Permalink

      I had prostate surgery in 2001 here in France. Spent a week in the hospital, had biopsy and x-rays and physical therapy. All I paid for was the telephone in the room. (I had no cell phone yet.) Yes, there are sometimes long waits to see a specialist (6 months for an ophthalmologist), but “urgent” needs are usually answered quickly. Too bad, politicians here seem intent on turning it back. Here’s hoping they don’t manage.

  35. Matt
    Posted November 10, 2020 at 11:56 am | Permalink

    I was given propofol for my colonoscopy. When I was waking up I just wanted to be left alone to sleep since I don’t normally sleep well. I can see why people get dependent on it.

  36. EdwardM
    Posted November 10, 2020 at 12:11 pm | Permalink

    In the US 62% of personal bankruptcies are because of medical debt, in most years that’s more than 500,000 people. More than 70% of Americans with medical bills have reported that they had to reduce their spending on food and housing in order to avoid bankruptcy.

    Medical bankruptcy is almost unheard of outside the good ol US of A. Once again, we’re number 1!

    Here’s one of many sources; https://worldpopulationreview.com/country-rankings/medical-bankruptcies-by-country

  37. littleboybrew
    Posted November 10, 2020 at 12:11 pm | Permalink

    Dr. Coyne, you hit the nail on the head. What other purchases does one make where you are not allowed to shop around to compare costs and services? Our medical care system is in need of serious overhaul.

  38. David Fuqua
    Posted November 10, 2020 at 12:26 pm | Permalink

    Don’t discount the importance of the cost of malpractice insurance premiums in the total cost of healthcare in this country.

    • Stuartg
      Posted November 10, 2020 at 1:40 pm | Permalink

      The contribution of indemnity insurance to medical costs in the USA is often not considered.

      A few years ago I talked with a USAnian colleague in a similar medical job. I was astounded to learn the cost for his indemnity insurance was almost twice my gross salary! At that stage, in New Zealand, my indemnity insurance was a reimbursed $1100 pa. It’s no wonder medical staff in the USA health system charge so much with such costs being incurred.

      NZ has both state funded and private health systems. The costs in the private system seem considerably less than those in the USA. As an example, for the same amount Jerry has been billed, the private system in NZ would be able to perform open cardiac valve replacement surgery.

      When my father had what I considered unacceptable wait times for cataract surgery in the public system, since he would have lost confidence in driving whilst waiting, I paid for the private procedures. Under $3,000 each.

      I work in the public system because in my early years I grew up seeing the benefits of the NHS in the UK, believe health care should be available at minimal cost to the patient, and cannot personally justify charging fee-for-service to my own patients. Despite this, I can also see and benefit from having a private health option available.

      The health system in the USA appears to be completely broken from my point of view. Unfortunately, I don’t have any idea how things can be fixed, other than making the observation that it is going to require change from within.

  39. ronsch99
    Posted November 10, 2020 at 1:30 pm | Permalink

    The difference between our wait times and Canada’s for elective procedures is due to differences in the distribution of health care. Our health care is maldistributed where those without insurance aren’t getting the same attention to their health care as others. Shorter wait times are being paid for by the many people who aren’t getting the attention to their health care that they should be getting.

  40. clarkia
    Posted November 10, 2020 at 1:42 pm | Permalink

    As an at-times user of both the Canadian and American health-care systems (and with family members both sides of the border) a few points:
    – the non-urgent care wait times in Canada can be ridiculous (examples: joint replacements).
    – the urgent care can be very impressive in Canada. I think there may be economies of scale that give the Canadian providers some relative advantages.
    – Having universal health care has benefits not included in the direct cost calculations including reduced hassle, peace of mind, and of course not losing your retirement savings due to unfortunate events. It may also (some speculate) reduce the overall religiosity of the country (i.e.lower life-stress).
    – Canadians I know well (at least 20+; a non-random sample!) would absolutely not trade their system for the American one.

  41. Joe Routon
    Posted November 10, 2020 at 1:55 pm | Permalink

    On vacation several years ago I had to have a root canal performed in Krakow, Poland. I received excellent care and was presented with a bill for $24, which included x-rays.

    As the dentist instructed, I went to my own dentist here in the States two weeks later to get the second half of the procedure. He gave me a bill for $2,000. I complained that he had only done the second half and shouldn’t charge me for the whole procedure. So, he deducted $24 from my bill.

    I decided to find a new dentist.

  42. Diana MacPherson
    Posted November 10, 2020 at 2:17 pm | Permalink

    Here are the current wait times for surgeries in Ontario (my province). This includes the back log from the COVID shut down in the Spring.

    You can move around that site. It’s got wait times for other things and you can further divide the surgical wait times for different conditions and look at paediatric surgeries vs. adult surgeries.

    • Posted November 10, 2020 at 3:59 pm | Permalink

      If I am reading that correctly, Jerry would wait somewhere between 15 to 41 days for a hernia op. Not too bad.

      • Diana MacPherson
        Posted November 10, 2020 at 4:03 pm | Permalink

        Yeah and they are still trying to catch up from earlier lock downs so pre covid it may be better. And these stats (for Ontario only because that’s where I live) don’t track emergencies because those are seen immediately. Also the cartoon of the woman waiting for her breast cancer surgery is way too calm. I didn’t look like that at all but the wait time was exactly what I experienced – about 15 days from diagnosis to surgery.

  43. Blue
    Posted November 10, 2020 at 4:13 pm | Permalink

    I do not know IF Any knows the answer to
    my query: What ‘ld happen, AT the end of
    one’s life, IF one did not pay insurance
    premiums … … AT ALL ?

    We keep referring to our ” having insurance; ”
    B U T
    I have a public university’s plan ( including
    its dental, invoiced separately ). It is
    stated to me, by others, that it is ” excellent. ”
    Allegedly.

    B U T

    I PAY through the nose for it = PREMIUMS =
    THE absolute highest cost PER each of
    my retired months. AND I use it NOT … …
    AT ALL. NOT even for mammograms which
    I have, upon family history and research,
    stopped having performed.

    I am at age 72, utterly healthy. My plan pays
    NOTHING for SO – helpful, SO – healthy endeavors
    which I like ( although ‘ve, since pandemic,
    had to suspend two ): steam room, the gym,
    a thoroughly researched and individualized
    supplements’ regimen, daily flossing and
    oral debridement.

    All four of these over the last 30+ years
    and accountable, I, a medically trained
    indivudual, believe, for why I am so healthy.
    Those premiums I PAY FOR, thus my “having
    insurance ” pays for SQUAT of those.
    I tried, by the way, to get my companies
    TO pay for portions of all four of these
    items … … and NO. Resoundingly NO.

    So. IF I were to STOP, right now at age 72,
    and were to live to my goal of age 103,*
    fairly healthily …, STOP paying one more
    damned $331.00 – monthly premium, and
    INSTEAD, PAID OUTRIGHT OUT OF MY ” OTHER ”
    POCKET THEN, in full a bill like Dr Coyne’s
    above, say, WILL I COME OUT $ – AHEAD ?
    At age 103 ?

    Blue
    *At my usual gym ( not pandemically now, o’course,)
    Ms Dixie there literally TREADS and LIFTS circles
    around the REST of us younguns. She is a
    retired nurse – yeah. And, today, 94.

    • Blue
      Posted November 10, 2020 at 4:30 pm | Permalink

      Oooo, I need to be clear: that $331.00
      is the monthly amount that I PAY for the
      ¡ supplemental ! and dental plan.

      That $331.00 is OVER and ABOVE that which
      I already PAY for Part B of Medicare … …
      which many o’AllYaAll ll know is
      an automatically TAKEN OUT – amount … …
      from what One is DUE. Also, monthly. I have
      no choice in that, that is.

      ANOTHER $134.00 / MONTH.

      Blue

      • Blue
        Posted November 10, 2020 at 6:04 pm | Permalink

        A wee reference point from some quick math just now:

        At THE rate today with no changes ( which is
        soooo NOT likely ) and over the next 30 years
        until I, then, become 102 years old and,
        thus, at today’s ” insurance ” rate of
        $5,580.00 per annum, I shall have been TAKEN
        by these healthcare entities including the
        federal government’s Social Security –
        dropped amount ( for Medicare ) for thus:
        very, very close to… … $168,000.00.

        And for my goal of age 103 ? and for nothing
        else but for insurance premiums then ?
        nearly $175,000.00 … …

        Blue

  44. J Cook
    Posted November 10, 2020 at 4:25 pm | Permalink

    Perhaps you could send your story and the comments to the Secretary of the SCOTUS.
    They are again, about to decide our health care fate.

  45. Billywindsock
    Posted November 10, 2020 at 4:31 pm | Permalink

    I had the exact same same operation four years ago here in the UK. The school I worked for had private medical cover for staff. I got to see the same surgeon, I just had a six month cut in the wait for my op. I paid £18, for the two painkiller presrciption drugs I took home after three days in hospital – I didn’t have keyhole, I’ve got a big scar. I am sure I can feel the mesh sometimes, I had two nerves (deliberately) cut and I get some discomfort in the area from time to time.

  46. amyt
    Posted November 10, 2020 at 6:30 pm | Permalink

    One big shock to bills may be to anesthesiologists and other personnel in the OR. We all know we should choose those in our @netwrk” to avoid @out if network” providers. Your surgeon may be in network but the anesthesiologists may not. Ouch!! Big unexpected charge.

  47. Douglas Keck
    Posted November 10, 2020 at 6:51 pm | Permalink

    I live half time in France and half in the US. I am very familiar with the health care systems in France and the UK.I have a daughter living in each of them. Their health care is just as good as ours and they spend vastly less than we do. If We spent the same percent as France we would have everybody covered and would have $3800 annually left over for every person in the country! American healthcare is a disgrace!

    • Diana MacPherson
      Posted November 10, 2020 at 7:10 pm | Permalink

      I’ve often thought a universal health care system would be the best in the world in the US because they have a massive tax base. We only have 38 million people in Canada that are spread over the second largest land mass in the world. Deep pockets of sparsely populated areas and a population that mostly lives near the US border and especially around the Great Lakes….yet our universal health care is pretty damn good. Look at NZ. Their’s is even better in some ways. They have an even smaller population of just under 5 million and they manage to even have pharmacare. Of course they don’t have the geographic issues we do but Australia does. A population around the edge, mostly the southern edge and sparsely populated everywhere else. A smaller population than Canada and a very good universal health care system. The US has well over 300 million people with fewer unreachable areas (Australia has vast desert and Canada has vast tundra which is really desert). Imagine how great it would be!

  48. JMark
    Posted November 10, 2020 at 7:24 pm | Permalink

    Actually, as noted elsewhere on this thread, Insurers are allowed to keep a maximum of 20 percent of premiums collected, with the other 80 percent going to the health care providers. The higher the bills, the higher their 20 percent is.

  49. Posted November 11, 2020 at 1:59 am | Permalink

    There are several other countries in the world than the US, Canada and the UK – or so I’ve heard.

    Seriously, and reducing my temper here: if you look at the cost/health structures (and outcomes – damn, just look at covid numbers!) of Australia (where I’m from), NZ and Japan (both where I’ve lived), Taiwan, Singapore and Switzerland ….. all do better, cheaper and generally live longer than us.

    Find a tourist from one of the above and ask him/her what “medical bankruptcy” is – they won’t know – you’ll have to explain it. Really.

    Ours system is sh*t b/c it isn’t capitalism at all – it is crony capitalism.

    Oh. BTW – that orange juice you bought with your groceries last month? That’ll be $1,200 thank you.

    D.A., J.D., NYC
    https://whyevolutionistrue.com/2020/06/10/photos-of-readers-93/

  50. Alexander
    Posted November 11, 2020 at 3:13 am | Permalink

    Watch out for a possible hacker active on this list!

    The email looks like any of the other comments, except that the subject line contains the word “SoundEagle” and also “Why Evolution is True” between square brackets.
    The message invites you to “click here” to see the comment. Delete this message permanently.

    • jezgrove
      Posted November 11, 2020 at 4:59 am | Permalink

      SoundEagle is not a hacker and the link is legit – I have had a few similar messages from other WEIT readers. Clicking on the link genuinely takes you to a comment that you have made and which the reader sending the message appreciated. I’ve no idea how they generate the email as I don’t see a “Like” button next to comments here, but it seems to relate to having your own WordPress website.

      • Diana MacPherson
        Posted November 11, 2020 at 10:38 am | Permalink

        You can do the liking if you use the WordPress client and have a WordPress account (don’t need your own blog).

  51. infiniteimprobabilit
    Posted November 11, 2020 at 3:24 am | Permalink

    The fundamental reason for all this is insurance costs; and the reason for that is the legal ‘American rule’ that losers in a court case do NOT (by default) pay the winner’s legal costs.

    This simply means that there is no deterrent to suing a rich target (such as a hospital or anyone with insurance) in the hopes that a sympathetic jury will award a few hundred thousand or a few million to the poor injured plaintiffs *even if there is no merit to their case*. So ambulance-chasing lawyers are happy to undertake such lawsuits on a no-win no-fee basis since, if they lose, they’ve only lost their own time, and if they win they get a fat payout.

    In most other countries, the losing side has to pay the legal costs of the winning side. This means there is far less inventive to launch predatory speculative lawsuits in the hope that the victim will settle out of court. It also means much less work for lawyers, of course. But it also means that being sued (or suing someone) is regarded as a last resort, and most people in such countries have never experienced this peculiarly American pastime.

    cr

    • Alexander
      Posted November 11, 2020 at 6:56 am | Permalink

      Who is going to pay for all these legal cases Trump is losing serially?

      • infiniteimprobabilit
        Posted November 13, 2020 at 3:14 am | Permalink

        On past form, it will be anyone-but-Trump.

        cr

  52. Chris
    Posted November 11, 2020 at 7:06 am | Permalink

    Is this something the new President Joe Biden, Vice Kamala Harris, their friend Bernie Sanders, and the Democratic Congress and Senate would not be able to do?

    It seems that theoretically they could fix this situation.

  53. simonchicago
    Posted November 11, 2020 at 12:23 pm | Permalink

    Actually, there is fairly good information about the costs *after the fact*. Blue Cross will send you a detailed account, where it becomes clear what is the price they negotiated with the provider (usually 40-60% of the “sticker price”.)

  54. KD
    Posted November 12, 2020 at 5:04 am | Permalink

    If you can buy X for price A in location P’, and sell X for price 2A in location Q’, you have an riskless arbitrage scenario.

    So can we be surprised when doctors from English speaking countries relocate to America where they can make 200 to 300% what they can make in their own countries?

    The best way to avoid brain drain in the medical profession for places like the UK and Canada is to make compensation levels in America comparable to reimbursements in other English-speaking countries. [I say English-speaking because it is easier for a fluent English-speaker to relocate to America and have their credentials recognized than say a Russian or a German.]

  55. Matthew Jenkins
    Posted November 12, 2020 at 5:23 pm | Permalink

    Professor, it looks like it would work out a fraction of the price to fly to the UK, have it done in a posh private hospital such as the Nuffield, and recuperate in an agreeable hotel.
    I’ll try to remember to pop in to work tomorrow and check the price of the mesh. I’m fairly sure they’re not all that expensive. Maybe you need a special mesh for robotic surgery.


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