You would think more Americans would fly to India to get expensive medical procedures done. Or are there other issues that need to be overcome to do this?
Besides, Cuba is closer. Canada is also a bargain compared to the US and you don't even have to violate state department rules.
However, ironically enough, the USA has a booming medical tourism industry also. At about 60-80k, it is only half as small as India (150,000), though nowhere near Thailand (1.42 million).
But its not just greed. Greed is also whats driving the Indian entrepreneurs to try to offer the surgeries cheaply and en-mass. Its more than that. Its unfair exploitation, regulatory capture, raw corruption and senseless parasitism. Its greed mutated and run amok. Its what happens when you get greed wet and then feed it after midnight.
I found it fascinating how this goes way beyond wage differences -- it's a serious focus on fiscal efficiency. The entrepreneur behind this has opened 21 new hospitals in India focused on bringing more affordable care:
"...he has cut the price of artery-clearing coronary bypass surgery to 95,000 rupees ($1,583), half of what it was 20 years ago, and wants to get the price down to $800 within a decade."
This leaves me wondering: Where is the innovation toward affordable care here in the USA?
I don't know much about the American healthcare system, but wouldn't it be the same incentive when selling any product? If you sell the same quality product for cheaper, you will get more business than your competitors.
The high barriers to entry in the field make it conducive to collusion. I'm not saying there is collusion, just saying that given that the supply isn't going away and that new upstarts cannot disrupt the market, you may make more money by not competing on price.
That's how it should work. Unfortunately, the U.S. healthcare system isn't really a free market. There are many laws and regulations (and insurance company imposed rules) that prevent healthy competition in the marketplace.
The US healthcare system is nothing close to a free market. Every step along the way is rigged: the schools that grant medical licenses is artificially gated, you require certifications you need political clout to obtain to open a medical facility, you need to have enough money to play ball with insurers so you get paid for operations, you need to comply with thousands of federal regulations surrounding your procedures, you need to get zoning permission from wherever you are trying to set up shop to even build a medical facility (note that local governments are easily bought out by the hospital chain in their area).
There is also an incredible amount of corruption surrounding drug prescription and diagnosis to get people buying way more drugs than they need to.
It isn't anything close to a free market. I could never open a health clinic out of my garage and put out a sign saying free anything related to medicine. By comparison, India has much more volatile healthcare (because they can't police everyone trying to play doctor) but get innovation as a result.
I have thought many times of moving to another country (India being high on my list) just so that I could learn and practice medicine outside of the US Money/Chemical game called "healthcare."
Please don't ever suggest a Michael Moore production as suitable for increasing one's knowledge on a subject. At best the man is an entertainer, nothing more. His works have about as much claim to the title "documentary" as does reality tv.
What free market? What prices? Free market from price shopping you say?
You got hit riding your bike and are bleeding profusely from your abdomen. The ambulance driver asks, "There's a hospital 6 minutes away but they don't post their prices publicly (who does?) and we've never brought anyone of your condition there before. We think it will probably cost between $500-$10,000. But there's a hospital 45 minutes away that we know for sure will cost $400-$800. What do you want us to do?"
Let's suppose the government mandates that all hospitals must post their prices publicly. But you're bleeding to death. Can you really go shopping now?
A large majority of medical care is not for people in imminent danger of dying. Even procedures for people with the time to shop around are vastly overpriced and do not have prices posted publicly.
Largely, on the lower end of the spectrum. Doc in the boxes for routine acute care, nurse practitioners substituting for doctors, pediatric medicine (+), etc.
+ One business model is "Pay a flat fee of $50, cash on the barrel. Your kid gets to see a doctor in under 15 minutes. You know and we know that 98% of the time it's just your child being sick with a routine illness. We'll write the prescription if required and rule out anything more serious. If it is anything more serious, we'll explain your escalation options."
The first supposed fact thrown around in the medical costs argument like this is, "Well in India their cost of living is lower, so they charge considerably less, yadda yadda..." but it's obvious the price difference goes way beyond any cost of living gap. That's over $100,000 in price difference, while it is true the cost of living (salary, prices of every day items) in India is considerably less than that of the US, the gap certainly isn't 100k+
It's comparisons like these that really make you sick to your stomach. You don't see this kind of innovation in the American health system because it has been engineered with greed in mind right from the start. The lobbyist super groups, hospitals being paid kickbacks for using an exclusive medical equipment provider, the money hungry mentality of US medical corporations is more than obvious.
I think when your medical system becomes so expensive it's cheaper for people to fly out of the country, pay for accommodation and even some spending money to get the same level of care, if not higher than that of your own country, regardless of cost of living differences and other nation specific costs that's absolutely ridiculous. By the sounds of it, India is going to be the new global superpower if more and more people fly there to pay for medical treatment it benefits their economy in the end (given how a substantial chunk of the population is below the poverty line, this might not be such a bad thing).
A doctor trained in India is no less qualified than a doctor trained in the US. So expertise or training is no excuse either. In-fact I've found Indian trained specialists to be more thorough, careful, understanding and compassionate in comparison to that of Australian trained medical professionals (I'm from Australia). When was the last time you saw or heard of a poor American medical specialist or surgeon?
The question is: Will America ever change their ways? Or will quality medical care only be reserved for those who can afford decent medical insurance or have jobs that provide fair medical benefits?
One thing is for certain, this is submission is going to garner a lot of responses from both sides of the fence if past submissions along these lines are anything to go by.
> It’s also pretty staggering that hiring qualified staff doesn’t appear to increase this probability. Das and colleagues suggest that part of the issue might be the variation in the quality of instruction in Indian medical training institutions. So there may be some institutions from which a qualification does make a difference. But given the paper’s results, the effect of such institutions must be rather small. The fact that providers working in better equipped facilities don’t have a higher probability of prescribing the right treatment is also alarming.
Obviously, heart surgery isn't rocket science, and our medical training is a bit overpriced, but is it so easy to compare two disjoint systems?
For what it's worth, there's a huge range of private care in India. From expensive hospitals that cater primarily to the upper class to charlatans without a degree holed away in a slum.
The difference between these two ends is incredible. While I can imagine these results at the latter, I find them hard to believe at the former. I'm paywalled away from this for the next two weeks, so if you want the facts, that's where I'd look: what sort of private healthcare.
That article doesn't actually compare India to the US. In fact, it says that "It’s also likely the results aren’t India-specific." It would be interesting to see the results of a similar study carried out in the US or UK, for example.
In any case, there is a difference between the general level of competency of doctors in a given country, and the level of competency available to wealthy foreigners travelling to the country for medical tourism.
It's not India-specific. This is definitely happening in Eastern European countries, too, and probably even some of the western ones (although a bit more) - just like with college tuitions.
There's something seriously wrong with both the healthcare system and the education system in US if the prices are 20x+ more than in any other country.
This is definitely happening in Eastern European countries, too, and probably even some of the western ones
Careful here. I live in London for several years now, and from my experience Eastern European doctors are much better qualified then Western European. I'm originally from Poland, and medical studies are really hard, and people spend whole 6 years cramming just to become an apprentice to the doctor (it's Bachelors and Masters degree combined). On the other hand in western countries you can do undergrad degree in anything and only then apply to med school.
If you do your bachelors in non-science field, you cannot get admitted without doing a post-baccalaureate, which can take 1-2 years additional. There are a lot of science requirements to even apply to medical school, that someone with a computer science degree, for instance, would not meet and would have to take those courses (i.e. biology, chemistry, biochemistry, organic chemistry etc.)
Same reason why many people in the Netherlands got their eyes lasered in Turkey. Both cheaper (including the flight) and better qualifications (if anything by experience).
This was a few years ago though, from what I've seen the costs for eye lasering here seem to be catching up a little.
Frankly I'm a bit surprised by all the people in this thread saying "well that's a huge price difference, but how do you know Indian doctors are as good as US doctors"--as good? On what basis is the default assumption that US doctors would be better and the Indian ones need to prove themselves? All I know of the US healthcare system is that it's ridiculously overpriced, but just like that $8 bowl of ramen (wat) someone mentioned upthread, doesn't mean it's better, it might even be worse.
Because everyone born in a capitalist society has been taught from day one that "the more expensive the better." Just as you would assume a $200k car is a really good one.
> On the other hand in western countries you can do undergrad degree in anything and only then apply to med school.
This isn't quite right. If you want access to anything but a fly-by-night medical school, they're wanting hard science and most likely a focus in biology.
I read about this clinic somewhere else, and there it was said this clinic actually outperforms western clinics in terms of complications, which seems to be achieved through staggering case numbers per doctor.
That makes sense: experience increases performance, which is why we have intensive residencies; there is a reason why until recently residents were working 80+ hours a week. Perhaps we should ship all our resident-ready medical students off to third world countries where the needs are great so they can become proficient very quickly. Perhaps our system has become too soft.
There’s a cumulative “in-hospital” time cap of 80 hours/week (88 for neurosurgical residents). In practice, however, this means that (a) the cap is regularly broken or (b) residents end up doing preparatory study, reading papers, doing research, etc outside of the hospital to remain under the cap. They are still working more or less the same hours.
Also, the 16 hour/day rule is only for interns, IIRC. Resident shifts can go up to 30(?) hours.
It's completely meaningless to compare mortality rates. It's also not clear that if a patient had a CABG in India, went home and dropped dead within 30 days, that this data would actually be captured rigorously.
Anyway, you're drawing the wrong conclusion - it's astounding how close the US mortality rate is to the Indian, which attests to how good the US system is at operating successfully on more complex, elderly patients. Of course, you could argue that the US has optimised the wrong thing, at great expense...
> Anyway, you're drawing the wrong conclusion - it's astounding how close the US mortality rate is to the Indian, which attests to how good the US system is at operating successfully on more complex, elderly patients. Of course, you could argue that the US has optimised the wrong thing, at great expense...
Is that connected to the extra funding that older people get?
What happens if we compare mortality in people under 65?
It's still going to be problematic. There is a hidden selection bias that you can't get around. Eg in India there are still a lot of people that can't afford the CABG no matter how much it costs. Are those people less or more likely to die after surgery than the people that do get operated on? The answer invariably would be yes.
Do centres that do more surgery have better outcomes? The answer to this is already a resounding yes. There isn't any doubt about that, it's been shown over and over again for multiple different surgeries within developed countries. Surgeons knows this, and so do health insurance companies. But of course this has to be asymptotic. Doing 1000000 CABGs doesn't make you 1000 times better than the surgeon that does 1000. So I doubt there is any real difference between the surgical skill in Shetty's centre and top institutions in the US. It's an untestable question in any case. The important point is that the care overall seems grossly non-inferior to the US, not that the US is inferior.
If their doctors are trained like the bulk of their it professionals -- those hired by the body shops, no thanks. At least from what I've seen, countries that make a business iut of pudging grad numbers hoping for expat acceptance, quality is inversely proportional to quantity.
Within the US, the cost of heart surgery is highly variable, but if I were to go international, i would go south/central America over India any dry.
Such a crass generalization. If you think the bulk of India's IT professionals are bad - then you should at least consider if such poor skills are "good enough" for a vast majority of IT work.
The Doctors and Engineers from the best institutes of India are comparable to the best in the world. You will regularly meet them in American or European hospitals anyways doing consulting. It's a poor comparison. Some of the hospitals in India are comparable to any top-class hospitals in the world. In the end, you will be visiting such a hospital in India, not small time ones.
thats quite a narrow minded comparison. Theres a significant difference between bodyshopping IT employees because western companies want to save money on IT and consider it commodity, & training surgeons. Having lived in both India and South America - I found the quality of healthcare in India significantly better. You need to think a bit before making comparisons! Besides - learn how to spell ;)
While the results of the studies are true in that study (that those fake patients were misdiagnosed), the assessment that why they were misdiagnosed is (may be?) not directly related to their competency.
As a Indian (who comes from relatively simple background), I don't need a study to tell me that general/govt. hospitals that provide PHC are overcrowded, lack necessary support staff, lack necessary equipment.
What the bloomberg article is talking about is, another class of hospitals and medical staff. Narayan Hridayala, Fortis etc employ pretty good doctors.
I doubt that, any general statement can be made about - "doctors trained in India are less qualified than US", because it depends on lot of factors.
At face value this appears to be a huge opportunity for innovators to take on the whole existing healthcare industry here in the USA.
In reality I think many healthcare entrepreneurs either get caught in the existing framework (and dependent on it), or find the regulatory and other hurdles too hard here.
That said, I still think there is a LOT of room to improve cost efficiency here, and the right entrepreneur could do it. It's been done in other stagnant segments of the economy... I would like to see an Elon Musk-type entrepreneur open efficient hospitals here like this guy is doing in India.
A huge problem in the US is all sorts of really really bad laws. For instance to open a new hospital you have to get permission from other hospitals in the area.
That's the opportunity. Eventually regulatory capture and corruption will become so great in the US that it really does become impossible to actually provide the care. Nothing will make it through the wall of parasites.
The opportunity is in helping Americans get real healthcare outside their borders. Take a glance Uber's way. You'll know you've got it right when there's serious talk about making it illegal to travel abroad to obtain medical care. For the safety of the people and the necessary good of the lowly American doctors, of course.
I think that it is already forbidden in some countries to get specific medical treatments abroad. It is so wrong, and I would not be surprise if it is going to happen in U.S.A. too.
regulations forced my doctor of thirty years into selling his business. Talking to him it pushed a lot of single and dual doctor offices into selling. Electronic records keeping was the bogeyman that pushed a few over the edge, between the software costs and the manpower to get all the documents into that now required form they just didn't have the money.
Top it off with his worst payers were not the insurance companies but government based.
Government regulation, from deciding what insurance must cover for all people to not being able to shop across state lines was very much responsible for the rapid increase in healthcare. It didn't help much when we got sold out by Washington under the guise of Affordable Care to the drug, insurance, and hospital, companies. ACA was payoff for campaign contributions, that is why no one read the damn bill.
I think someone like Elon Musk is capable of doing such a thing. But the complexities of the law around the medical industry definitely don't make it easy and even after you're up and running, infiltrating a lobbyist dominated niche is the next hurdle.
I'm not sure if you've heard the story but there is an American inventor by the name of Thomas Shaw. He invented the first safe, retractable syringe that was more reliable than any existing solution. Companies tried copying his design and managed only to produce sub-par copies, it's an interesting read. http://www.washingtonmonthly.com/features/2010/1007.blake.ht...
>>You don't see this kind of innovation in the American health system because it has been engineered with greed in mind right from the start.
As an Indian, I can tell you people here think the same about our health care system. The Doctor in discussion here, Dr Devi Shetty is a sort of a local hero here in Bangalore. And who knows in some years he might as well be a national hero. Its basically because he seems to bring in advantages of doing things in volume + some health insurance based innovations into the whole equation. And I do agree that he is pragmatically altruistic. But such people are exceedingly rare. We are simply fortunate to have him.
I've never been to US, but I can tell you the Indian health care system is if not less is equally greedy compared to their US counterparts. Its just the same.
These days if you don't have health insurance you are more or less screwed. Its just like the US. I mean from whatever I've read about US so far its the very same. Nothing changes. You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x value of your money. That is what it is at the end of the day.
Coming to our system. Forget greed, fraud in the system is so massively high nothing that I write here will explain it. It is extremely common for doctors to order lab tests wholesale even if they are dead sure the patient has no problems at all. Doctors get commissions from testing labs/pharmacies etc for ordering lab tests, medicines. Treatment is purposefully prolonged, patients made to eat all kinds of antibiotics, undergo all sorts of non sense tests because doctors get commissions for it.
The fees for completing your medical course is astronomically high. Capitation fee often runs in crores, the net fee by the time you finish your MD is so high no doubt most doctors have to practically turn into crooks to get something out of it. Add to this nearly more than a decade of studies sets a perfect stage for these sort of activities to happen.
Its just the same old game, as you see in US. Just served differently.
> You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x value of your money. That is what it is at the end of the day.
I find the vast majority of people are tripped up by currency conversion, but I'm surprised to find this on HN. In Japan $1 = 100 yen, but certainly I don't feel I have 100x in buying power. A bowl of ramen will cost me $8 in SF; an equivalent bowl will cost me 800 JPY in tokyo.
I'm surprised that how many otherwise smart people gets tripped up by this. The only time you can deduce something from the exchange rate is if you compare the difference between the two rates over a longer period of time. Then it can roughly tell you things about difference in direction of inflation between the two countries, and the effect on wages and imports/exports. If the difference between the exchange rate between two countries doesn't change for a long time the prices of goods in both countries end up being roughly the same.
"If the difference between the exchange rate between two countries doesn't change for a long time the prices of goods in both countries end up being roughly the same."
Simply not true. Compare the cost of a beer in, say, Thailand and Norway. Are you suggesting if the exchange rate were fixed they would reach parity over time?
Assuming no new disruptions, then yes, economic conditions in the two countries would eventually equalize and prices would differ by at most the shipping cost if one of the two countries happens to have much better natural conditions for producing beer than the other. It's because disruptions are now becoming (have become?) the norm that equilibrium never has time to come close to manifesting itself.
I think it's a little more complicated than that. Culture plays a major factor, especially when it leads to niche markets. If a product has a niche demand in country A, and high demand in country B, then the cost in country A can easily remain much higher than the cost in country B. In addition to shipping cost being higher in that case (which is why that difference is hard to abstract away), you have to consider the opportunity cost of keeping it in inventory, the risk of spoilage if the product is perishable, the risk of depreciation if it's technology, etc.
Compare the cost of anything in Norway, and well, anywhere else. Norway is one of the most expensive countries in the world for foreigners because of it's abnormally high average income.
Yen is the equivalent of cents, not dollars, thats why the confusion, yen doesnt have a concept of 100 cents=1 xxx. In Rupees case it is an equivalent of dollars, 100 paisas = 1 Rupee.
So in this case 60x is a reasonable assumption except not including the Purchasing Power Parity.
In agricultural terminology you can either pay people 'by the day' or pay them 'by the hundred yards'.
I have worked in both types of systems and can see merits and pitfalls in both.
In the former system there can woeful output whilst in the latter there can be woeful quality.
Neither of these are inevitable.
In a salary system, if the lazy/incompetent can 'get away with it' and the industrious/competent aren't acknowledged it has a poisonous effect on the organisation.
In a fee per item system the lazy will earn less automatically but there needs to be careful monitoring of the quality of the output with particular attention paid to people at either tail of the output distribution.
Also people with high output (because of poor quality) can drive down wages for everyone and create a treadmill where the quality of everyones' work suffers as they try to maintain their income.
> If you want to incentivize outcomes and efficiency, fee-for-outcome is and obvious option.
When I write a contract, there are often two prices: a minimum which is stingy and a bonus which is far from it.
The point is to say that if you do the minimum for this contract, you get a certain amount; if you excel, you get paid for that excellence.
Translated to health care, I think I'd like to see doctors doing less paperwork and more doctoring. It's not perfect, but I trust competition to pay that excellence price to those who deserve it.
That in turn means that if I need some kind of crucial care, I know where it can be found. If the system is over-regulated, that is not so.
When it comes to medical care, you have to be really careful about how you define "outcome" if you want to use that as an incentive. You can't just use patient recovery/survival, because then you'd have doctors avoiding patients that need their care the most. You'd also continue to get extraordinary measures taken to extend the life of patients that can't survive, even when letting them go is the more humane thing to do to ease their suffering.
I've thought about this a lot, and I don't think there is any objective way to provide outcome-based incentives. The best I could think of is peer-reviewed judgements of outcomes, but that could become pretty corrupt.
For rare conditions and the very sick, there are a lot of thorny issues, and fee-for-outcome may be hard to implement well. However, those don’t represent the bulk of medical procedures; the vast majority of what’s done in a hospital is utterly routine and predictable, and the outcomes are most definitely quantifiable.
I am in Bangalore and don't have medical insurance. Paid Rs 300 fee to General Physician for a consultation another 1500 Rs. for a bunch of tests. In my hometown in Bihar the same thing costs Rs 150+500 with excellent doctors. It's not all rosy but it's not that bad.
The only thing I can tell you is to go and get health insurance ASAP. Both for yourself and your dependents.
Get one and be safe, one serious illness can bankrupt you these days(actually it always has). But my point is even a week of hospitalization can be pretty expensive. And don't be under an impression you will be able to travel to Bihar or wherever when the need arises. During cases of emergency those are not practical solutions.
Well I have a few doctors in my family so I know the intricacies. There are several hospitals/clinics in India which still provide affordable care. No one in my family has a medical insurance. We have had a few health emergencies,in metros too, but the cost was always managed. We only have Life Insurances.It doesnt make sense to pay someone else a hefty insurance premium every year, which may or may not pay back, when the best insurance you can have is a family who shares. You get sick, I pay and vice-versa. I think instead of an inflated health insurance plan we can have a friends or family plan where you get together put some money and use it whenever a situation arises. Hey! I have a startup idea.
We recently had a baby (in Aus). Our Indian neighbour (been in au for 7 years) was amazed at how little medical intervention we had. His comment was that in India there was much more incentive to recommend drugs, c-sections, etc.
>>I've never been to US, but I can tell you the Indian health care system is if not less is equally greedy compared to their US counterparts. Its just the same.
Its NOT the same. High costs in the US are essentially a result of policy corruption - a systemic issue with results in the exorbitant prices. Greed amongst doctors is prevalent in India as well as the US - maybe more prevalent in India due to general poverty. But health care in India is more 'free-market' than in the US, which is why it is more efficient.
>>I've never been to US, but I can tell you the Indian health care system is if not less is equally greedy compared to their US counterparts. Its just the same.
I have been to the US and I have spent a huge time in India. I have witnessed the Indian health system in close quarters and have close family members undergone major surgeries. There is greed in India, no doubt about it. But the American system is completely EFFED up - there is no comparison. If you go to the US and spend some time understanding/experiencing the system, you will be thankful for what you have in India.
>>These days if you don't have health insurance you are more or less screwed. Its just like the US. I mean from whatever I've read about US so far its the very same. Nothing changes. You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x value of your money. That is what it is at the end of the day.
You are completely wrong about this only because you don't know what happens in the US if you dont have insurance. My close family members have undergone major heart surgery at Narayanan Hrudyalaya. They had insurance, but even if the insurance did not cover it, it was not a big deal. I could have easily paid from my own pocket - it cost just over $2K USD - not a big amount for middle class Indians for life threatening surgery. All the prices are transparent - so if you dont want to pay as much you can choose cheaper options (shared post-op bedding etc.) which will reduce prices in half - with very little difference in medical care.
In the US if you dont have insurance for something like this - you will go bankrupt. The only reason you don't know about this is because most of your NRI friends work for bigger tech companies which provide good coverage.
Infact one of the reasons why health care is reasonable in India is because insurance coverage is limited and not mandated by law. The resulting free market delivers the economies quoted in this article.
>>Coming to our system. Forget greed, fraud in the system is so massively high nothing that I write here will explain it.
No it is NOT. There is a tendency in Indians to think that they are completely fucked up. Travel around the world - especially to the US and you will thank your stars - and please dont go with what NRI's say - they have a vested interest.
It is true that there is greed in the system and there is fraud - but there is a relatively freer market. You can 'choose' your doctors/hospitals. If you dont have a good experience with a hospital you can choose to write a review on Mouthshut.com and have them get less business. You can do your research and choose a better doctor/hospital over a worse one. This 'choice' and the enabling free market makes India health care deliver economies at scale which are impossible in the American system.
>>The fees for completing your medical course is astronomically high. Capitation fee often runs in crores, the net fee by the time you finish your MD is so high no doubt most doctors have to practically turn into crooks to get something out of it. Add to this nearly more than a decade of studies sets a perfect stage for these sort of activities to happen.
Assuming that this does turn them into 'crooks', they have an easy way to get their money 'out' - migrate to the US/UK after completing their residency. Some doctors are greedy, some are good. The greedy ones land up outsid...
>>I could have easily paid from my own pocket - it cost just over $2K USD - not a big amount for middle class Indians for life threatening surgery.
You could have, sure easily! Besides a person who has traveled to US doesn't fall under middle class category anymore. Sorry you don't. In a country where kids die of hunger and where parts of the country manage to barely eat two rotis a day with salt- traveling and working in the US is a rich man's luxury.
Sorry to be putting it this bluntly, but in India anybody apart from Mukesh Ambani thinks he belongs to the middle class.
Most people(The middle class- People who make around 10/15K rupees a month) can't pay for expensive medical treatments, medication, post-op follow ups etc and that's a fact.
>> If you dont have a good experience with a hospital you can choose to write a review on Mouthshut.com and have them get less business.
Yeah right. I find it hilarious when techies offer solutions like these to common people who don't even know how to turn on a computer.
I agree. A large portion of the population barely makes between 5-15k per month that is not sufficient for 3 meals a day + housing + school education. Forget surgery, they can't afford routine doctor consultation, diagnostic tests and medication. And yes, diagnostic tests are almost always done whether needed or not.
My cook makes 15K per month. Life threatening procedures are relatively rare. Incase he has to go through a similar surgery he can go for a 'package' which will cost him 50K. There are no 'noticeable' differences between the health care that he will get to what my family member got. He can afford 50K for something as rare and life threatening like this.
Mouthshut.com was just an example to demonstrate what it means to have a free market. My cook obviously can't access it - but he will ask me and his relatives on which doctor/hospital is good/cheap. He faces greater infomation assymetry - but the fundamental advantages of a free'r market still accrue.
I am not sure it is true anymore. If you compare cost of living in a good infrastructure or similar lifestyle you will find India is expensive.
I am sure many will disagree but just go ahead and look at cost of decent housing in any Indian metro.
We too have crap doctors in India like anywhere else, may be they don't sound too expensive when you go by USD conversion.
>> A doctor trained in India is no less qualified than a doctor trained in the US.
This might be objectively true (which you could reasonably determine through some combination of standardize testing and surgery complications/outcomes), but if you ask 100 people on the street in US whether they would prefer to see a US MD or an Indian MD for their heart surgery, I bet 97 or higher would prefer the US MD. The tiny remainder would probably show no preference.
Their is a brand power of a US medical education, which is especially strong for US patients.
I think it's probably just racism. I bet you'd see similar outcomes if you let people choose between white doctors and Indian-American doctors, even if the white doctor was the foreign one.
I agree but not sure if it's quite racism, more like prejudice. If it were a relatively poor or say (ex-) communist country with white doctors they'd be wary too.
I can't defend the US cost entirely. It certainly seems exorbitant. That said, I think there are some things baked into the US cost that most patients probably want. A certain degree of post-operative care that maximizes comfort under the circumstances, for example. Possibly also factors that affect the success of the surgery. Heart surgery isn't necessarily over once they close you up. It's great that surgery is being made so much more accessible, of course, but these procedures are probably not comparable.
Another question: why don't Indian doctors just import themselves to the US and earn much higher wages and profits by offering American customers something like the average of the Indian and American price?
Because they would have to get student status and undertake a two year residency, and then take the US medical board exams, and then come over on a H1B and work in a regular hospital (once they'd found one to sponsor them) and then get a greencard so they could work on their own and by then, maybe 10 years after they left India, they would probably be perfectly happy to continue living at the same wages instead of massively cutting their prices.
> The first supposed fact thrown around in the medical costs argument like this is, "Well in India their cost of living is lower, so they charge considerably less, yadda yadda..." but it's obvious the price difference goes way beyond any cost of living gap. That's over $100,000 in price difference, while it is true the cost of living (salary, prices of every day items) in India is considerably less than that of the US, the gap certainly isn't 100k+
Well, the article says 2/3 of people live on $2/day, implying this surgery is $1600/$2/day = 800 days worth of work.
Taking the US median income of $45k (since I don't know the 2/3 number off the top of my head), that implies the equivalent price in the US would be ($45k/365) * 800 = $98,630. So, right about the same as at the Cleveland Clinic.
The $2 figure quoted for Indian is not the middle 2/3, but the lowest 2/3, so it would have very little to do with the median. Let's go by the figures we actually have (mean):
Per-capita income in India is $1492
Per-capita income in the USA is $49,922
So, it's around 1583/1492 = 1.06 years of work in India.
And, 106385/49922 = 2.13 years of work in the USA.
And since the hospital price is actually 95k Indian rupees, exchange-rate fluctuations do not matter.
Here is what makes up the difference. In America, law mandates that hospitals treat anyone regardless of income, insurance possession or immigration status. Go to the hospital in India as an illegal alien and not only will you not get treatment, you will be jailed, then deported. Covering illegals and the uninsured is a HUGE cost that health care systems have to bear. Of course there are other things in America which drive up health costs, but treating illegals and chronically ill patients who have no insurance is the biggest. There are other major factors as well, but these laws alone bridge the gap in your calculations.
"A doctor trained in India is no less qualified than a doctor trained in the US"
Perhaps you are correct, but I doubt this assertion. U.S. graduate schools are generally the best in the world, I am not sure why that should be any different for medical schools
Hmmm. Why do you think it is that the costs of products and services produced by certain industries, like medical care and higher education, tend to rise much faster than inflation, while costs in other industries, like say, technology, fall over time? Could it have something to do with the fact that the industries where costs are increasing are those most heavily regulated and subsidized by multiple layers of government, while those where costs are falling (and quality is rising) are those that are least regulated and subsidized? Perish the thought! Much easier to just scream "greed!!!" and feel a bit morally superior than to actually try to understand what the problem is.
First off, this article is comparing the cheapest clinic in India, with the most expensive and most revered Heart center (Cleveland Clinic) in the world. NH is basically like getting your heart surgery done at a non air conditioned WalMart. There are no patient rooms. There is a patient room. A giant room with beds lined up civil war style. The food is akin to gruel, ETC... Of course there is going to be a significant cost difference. This is like comparing staying at a Hostile and getting dinner in the soup line with Staying a night at the Hilton and ordering a New York steak dinner for room service, of course there is going to be a significant cost difference. Leave it to a reporter to compare the cheapest abroad to the most expensive here (a bit of stretching to make the store line a bit more catchy).
Second, the reported cost is false. "NH maintains its costs low, savings that are then transferred to the patient. NH's cost of open heart surgery is USD $2,000. The hospital charges $2,400 to the patient, compared to $5,500 charged at an average private hospital in India."http://healthmarketinnovations.org/program/narayana-hrudayal...
Third, the per capita income in India is $1,000 nominal dollars, in the U.S., it's $50,000.
So the average adjusted open heart surgery in India is actually $275,000 when converting to USD and comparing using the average per capita income. (Narayana Hrudayalaya's "discounted hospitals" only charge $120,000)
I know that the average income does not fairly reflect the true cost differential because India has a disproportionately large population of people living in abject poverty. It does make the cost difference margin quite a bit less though.
If you are wondering just how places in countries like this can operate more cheaply though? I will tell you. US laws. In America the law states that hospitals have to care for anyone even non citizens. It also puts stringent regulations on hospitals. Regulations that do not exist in India. These Regulations are very expensive to comply with.
Narayana Hrudayalaya's establishments are not hospitals, they are not for emergency care. They do not treat non-paying clientele. In America, our medical costs balloon out of control for many reasons, one of the larger ones being the care of non-paying patients. Emergency rooms and therefore hospitals cannot turn away patients for any reason. They must admit illegals and uninsured (even for long term care). They cannot recoup money from these individuals so the paying customers get to flip the bill so the hospital can remain in business.
Just try going to an emergency room in India as an illegal alien. You will be promptly jailed and deported. Try going without insurance or means of payment... Good luck with that (same MO as all these countries where these "cheap procedures" can be had)
There are some countries where these procedures are still cheaper than in the US and they cannot legally turn away illegals and uninsured. They have a slightly different formula. The government flips the bill (subsidizes the hospitals) thus allowing them to compete cheaply (which keeps the costs low).
The reason for your colleague's stomach flu might be because of some unsafe food. Most hospitals and clinics are infact quite clean and well maintained.
30 day mortality rate is 1.4% vs. 1.9% in the US in 2008 [1]. The claim is that due to the high volume and single service, the surgeons get an awful lot of practice at the procedure and become very good at it.
Same here, got salmonella in Los Angeles eating at a subway. Point being, you can get sick anywhere, other factors include your body getting used to new organisms.
Would they? Or would the poor middle class people not being able to afford cancer-treatment/heard surgery just have a considerably lower life-expectancy?
I am not sure, so I really would love to see the numbers/facts supporting your statement. Would love to learn of this magic fact. [cynicism end]
[Edit]: Typo
[Edit 2:] In Germany, with full health-insurance the cost for a Cardiopulmonary bypass are round about 30k €. So a lot cheaper, than in the US, despite health insurance.
Just wanted to present a fact, not let my comment stand as cynicism only.
First of all, I am sure the 106K figure is a phony 'list price' figure and not reflective of how much is actually paid.
Second of all, you ignore the incredible sums of money taken from the 'poor middle class' and handed over to the health industrial complex.
For most of this country's history [the USA], there was no such thing as health insurance. The poor got charity care and the middle class were able to pay.
Why do you think cancer treatment has to be expensive?
I am not stating, that it might drive prices down. As I would not be stating, that it might drive prices up.
I wouldn't do this, because I do not have the necessary facts to make such a claim.
If a health-insurance system would work right, the health insurance agency might have a lot of more leverage in this highly regulated market, then any individual paying for its own. But that is just an assumption.
Well your next statement regarding my ironic "poor middle class" is just that: a statement, without any facts to support it.
I was asking for facts to support your statements. I even did some preliminary research into the costs of comparable healthcare in Germany (where I am from).
I just wanted to learn, if a "no health care" system might work better and be cheaper, but I will not just believe your statements, as that would just go against everything, I value.
So I really beg you, to show me verifiable facts substantiating your statements. Please?
If everyone had health insurance, and charity care that the hospitals currently eat the costs for now went away, then health insurance prices will drop.
That's a convenient fiction. Care to back that up with some evidence?
In particular, how do you account for the fact that more health insurance (Europe, Japan) is less constly than the abomination known as the US healthcare system?
The concept of health insurance is a bit fucked up in the U.S., since everybody needs healthcare.
My country has a system that, while bad, sounds absolutely awesome compared to the U.S. . It's a socialist system that is called Mutualism.
The best explanation I could come up with after some Googling is: http://www.hmg.gov.uk/media/60217/mutuals.pdf "Mutual organisations do not have external shareholders - they are controlled by their members. Members may be users of the mutual, employees, other stakeholders or a combination of these Mutual organisations are either owned by and run in the interests of existing members, as is the case in building societies, cooperatives and friendly societies, or, as in many public services, owned on behalf of the wider community and run in the interests of the wider community"
It does have several downsides - mutual healthcare institutions are strongly discouraged from doing any healthcare on non life-threatening situations, waiting lists for surgeries are way too long, there's corruption and doctor bribing and queue-jumping and strikes... but it "works", most people have good healthcare and don't get bankrupt if they need surgery, for just about U$ 100 per month, and their families have coverage too.
Another way to say this: Decouple catastrophic health insurance, what we use to cover actual medical emergencies, and routine health care costs. This is roughly the model in use in Singapore and similar to what people in the US with high deductible plans live with.
I work in the medical products field and it's amazing how much distortion is introduced into the system when "insurance" is used to pay for everyday consumables. Products that go from RX to OTC drop 80-90% overnight.
This is classic disruption at work. There are many procedures e.g. cataract surgery costs have come down but they are such cash cows that the prices were held high. India is doing this because skills can scale if there is a system of training. It wasn't too long ago when I read the Russians invented a factory-line method of doing eye-surgery.
Five years back,my father got both his eyes operated upon for cataract removal at Coimbatore,India as part of some free Eye camp program.This year, my mom had cataract in both eyes surgically corrected in a private hospital in North Kerala.They charged only Rs.9500/- per eye,and the treatment was quite good.Now my Mom has 6/6 vision in both eyes.
The situation in other Asian countries like India, Taiwan, or South Korea is nearly the same.
There are still some obstables.
A different environment and unknown results may be the major ones.
People should try to calculate the overall outcome and costs and maybe come up with some good international insurance packages.
Medical tourism has hurt most Indians. 1583 USD is almost 100k INR. The average per capita income in India is 1219 USD (72k INR). This figure too is very misleading, since poverty is a huge problem.
A very simple plotting with data from wikipedia and rudimentary extrapolation, shows that more than 1.1 billion Indian's annual income is less than the current cost of heart surgery. India's total population is 1.2 billion.
Medical tourism, though very fine for a lot of folks who want a cheaper alternative, is driving up the cost of medical treatments in India by leaps and bounds. This makes surgeries, that were already very expensive and out of the reach of most Indian's even more expensive and out of the reach of even more people.
> Medical tourism, though very fine for a lot of folks who want a cheaper alternative, is driving up the cost of medical treatments in India by leaps and bounds.
Any evidence to back this up? Your links and statistics are about how this specific cost is still out of reach of a lot of people. I don't think anyone is debating that.
> This makes surgeries, that were already very expensive and out of the reach of most Indian's even more expensive and out of the reach of even more people.
The article shows how the cost of surgery has dropped over time, and their goal being to drop it further.
In my country I know of a hepatologist who claims to have seen higher than normal rates of hepatitis B amongst people who have travelled to lower cost countries for dental treatment.
One country was mentioned in particular (not India as it happens).
Your comment left out the single most important piece of information: the country in which the treatment took place. I have no plans, and thankfully no need, to go abroad for low-cost treatment of any sort, but someone reading your comment might, and the key fact you omitted might stop them making a horrible mistake.
I was tempted to mention it. But what I am writing is hearsay until such time as this doctor goes public with it, if he ever does that.
If it's true it would cause a major controversy in the EU.
I'm just curious to know the situation in countries like Russia and China, because many of my friends took their medical degree from those Countries. Is is just the education is cheaper or entire industry?
I am from India. I think one major cost factor is price of medicine. In India, you can get medicine at very low cost compared to the west. Salary and dollar conversion/PPP are also major cost factors.
For instance, a urine test costs $1-$1.5 in India, urine culture is about $6, a USG scan is about $14. In USA, urine routine is $30, culture is $70 and USG is $750
Somewhere there is a forum of doctors saying "Pfft, the US firm wants $100k for the patient records system and the Indian firm wants $1,000. Those greedy bastards! They live in a toxic industry which acts as parasites on us noble public servants saving lives every day. It serves them right to deal with international competition finally.
Let's go with the Indian bidder. What could possibly go wrong."
Lots of stuff. But the question isn't about which of those two systems will be better in the end. The question is what to do when you've only got $75k.
Not sure what you're trying to say here. You seem to be trying to defend the cost of a $100,000 operation by making a snarky comparison with outsourcing an IT project.
patio11 has a long history of making snarky comments about how outsourcing to India should not be a concern to Western IT workers because the quality of Indian IT workers is much lower than that of Western IT workers and clients will ultimately recognize this and hire a Westerner instead. This is presumably something that is quite near and dear to him, as he is an American expat who lives in Gifu, a tiny, rural Japanese town. Since his primary income source (outside of Bingo Card Creator and Appointment Reminder) is doing consulting work for Western customers, it's very important to him that they pick him over Indian consultants based on how good he is, since hiring him presents all the same issues with respect to time zone, distance, etc. that hiring an Indian would.
He probably experienced a lot of difficulty initially in acquiring customers (who opted to go with the much cheaper, Indian consultants), which is why he has such an oversized Internet presence, including on Hacker News - it has helped build a brand for himself that isn't location-specific.
My long history of comments on the issue generally references my time at the old Japanese day job, where I was pressganged into dealing with our Indian subsidiary and asked to shepherd the five folks who came to work at our Nagoya location from it. This is what I was doing during three years of 100 hour weeks.
A more charitable read of my old comments would be "The project(s) were beset by communication issues, terribly managed by the Japanese company (which, in the fine tradition of Japanese companies, I'll take blame for since I was unable to resolve it despite trying), and additionally undermined by pervasive competence issues."
I'm not talking my book here. In the first place, I don't have a book, as I no longer consult. In the second case, Indian BPO firms are less competitive with me than Chinese take out restaurants: our target customers are different, our projects are different, our marketing methods are different, etc etc.
Once again, an attempt to attribute someone's words to simple financial interests or other superficial biases makes a whole thread dumber. Has this kind of argument ever worked on HN, even once? This attempt at psychoanalyzing Patrick is so comically ineffective that it might have been improved with a few intimations that he was also in the best pockets of the NSA.
No, I'm suggesting that HN commenters here are likely far less competent to speculate about the cost structure of heart operations than believe themselves to be. In an analogous situation which they actually understand, the tenor of this comment thread would reverse in a hurry. (Which we could ascribe partly to self interest but in major degree to "Deliver X for the US market in America" and "Deliver X for the Indian market in India" being two very, very different propositions.)
"I'm suggesting that HN commenters here are likely far less competent to speculate about the cost structure of heart operations than believe themselves to be"
In my case: U.S. cost structures, sure, I don't know them, though I do speculate and guess, and asked if someone knows of a hospital with transparent enough data.
Uruguay cost structures are a different bag altogether, since they're mostly government-run and they have to make numbers somewhat public. Add to that one of my brothers working in a hospital (he's a few years from graduating as a doctor) and other sources, and I can get an estimate that I hope is correct to an order of magnitude. A relative has been a customer of the Cleveland clinic, so I know the exact number he paid. I also know the exact number another person paid for the exact same surgery here in Uruguay - it was close to one-tenth, and he chose to pay private rather to go through the public institutions (which have huge delays).
Below is a PDF in Spanish, on an investigative piece from a weekly that goes into great detail on the costs of surgery in Uruguay. I'll just quote some basic numbers:
- Fixed fee per major surgery (medical act) UY$ 27.500 / U$ 1300
- Other heart surgeons, between UY$ 162.500 and 243.000 depending on seniority and other factors - U$ 8.000 to 12.000 range, per month. Those are close to the best salaries anywhere in Uruguay, usually as well trained as any doctor in the U.S.
- Cost to the hospital per major operation (heart surgery), UY$ 206.000 / U$ 10.000
Smaller operations like angioplasty cost UY$ 60.000 / U$ 3.000
The most expensive surgery is heart transplant, which costs UY$ 684.000 / U$ 32000
All those are set by the government, so those ARE the actual costs (well, actually they were in 2008, I didn't adjust by inflation and exchange rate), no insurance or strange stuff involved. The patient is not billed a cent, but there is a huge delay (months usually), and doctors don't really schedule surgery unless it's critical for the person's health (almost no quality of life procedures through the public system).
Some times, things really are that way. It does help to know the supplier, of course.
But back to the article, there are some U.S. healthcare costs that don't make any sense, I've seen procedures with firsthand accounts of an equivalent service here in Uruguay vs the cost in the U.S., and the cost in the U.S. is an order of magnitude more (and service sometimes much worse, this is the hospital I go to, try to argue it's worse than an average U.S. hospital ! http://www.hospitalbritanico.org.uy/ ).
Similarly, the company I work for regularly gets better software for one-tenth the price of U.S. bidders, we've bought local (Uruguayan), Colombian, Ecuadorean... it does help a lot that we know the language and how to do business there. It's not a hundred-to-one comparison as you mention, but there are huge market inefficiencies (in this case, they should be arbitraged away by someone selling services in the U.S., with a focus on quality and not devolving into Infosys or something).
Thanks to femto, we have some data. It seems that the 30 day mortality rate is lower than that in the US. Care to answer this other than with thinly veiled casual racism?
Dr Shetty's success rates appear to be as good as those of many hospitals abroad. Narayana Hrudayalaya reports a 1.4 per cent mortality rate within 30 days of coronary artery bypass graft surgery, one of the most common procedures, compared with an average of 1.9 per cent in the US in 2008, according to data gathered by the Chicago-based Society of Thoracic Surgeons.
Dr Lewin believes Dr Shetty's success rates would look even better if he adjusted for risk, because his patients often lack access to even basic health care and suffer from more advanced cardiac disease when they finally come in for surgery.
I will say that you are comparing one doctor to the national average. This only shows he is better than average, but what is the Indian average mortality rate. Another issue that your article mentions is that he specializes on a select procedure and another doctor mentions that this option of specialization is not available to all surgeons.
Don't take this as part of any sides argument. All I want to point out is that the numbers you provide only paint part of the picture. Yes maybe flying to India for this one doctors procedure would be worthwhile but is it true across the board.
Jayadeva Institute of Cardiovascular Sciences and Research, a popular hospital in Bangalore, publish procedure charges (in Rupees) on their website. Might be interesting for comparison.
I can assure you that the doctors doing 1-2 CABGs per day are not making $30M-$70M/year.
Alas I don't know how much the hospital takes, but I know that there are ~500,000 CABGs per year. I suspect that we as a nation are not spending $50 billion annually on CABGs, but I could be off.
I'd like to point out that the price difference is most likely to do with the marked conditions of the health care in general, and has nothing to do with the quality of the operation itself.
There is a big problem with health care in most countries that I've been living into for extended periods of time (France, Italy and to a lesser extent Germany).
Anything sorrounding "medical" and/or "health care" has a 10x-100x price blowup, for absolutely no reason. I'm not even speaking about surgery, I can start by phisiotherapy consumables, such as elastic bands. Elastic bands are used in phisical rehab. They are dirt cheap, usually, if you buy them inside a child play store. But behold, if you buy the same stuff from "Thera Band", which is officially sold to hospitals and clinics, a couple of meters of the stuff will cost you 20-30 times more. I worked as an assistant in a phisical rehab clinic for several years, and this kind of bullshit is amazing, because it goes for everything (air balls, plastic rods for balancing excercises, and so on). The price inflation goes even higher with actual machines.
There is a machine which is called "Rehab 3xxxx" (produced by a clinic around here which I helped develop, so I won't disclose the details), which is just a linear actuator which moves back and forth. Literally, nothing more. There is an embedded controller which allows to tune the extension limits, and a couple of ABS plastic accessories that hold to the knee, wrist, etc.
The idea is just to move the articulation, and/or rotate it, over and over. You would think that there is something "fancy" about it, to name a few details which I wished this machine had:
* force feedback to stop the motion (right now the machine will just twist your arm as configured, no matter the force)
* speed regulation (who needs it? just one speed is good enough)
* some sort of patient-id so that you don't need to reconfigure it each time
But not really. Like I said, this is just a dumb linear actuator, with incredibly cheap ABS plastic accessories and a fancy name. Price? 30k euros in the basic kit.
The funny part: for anything medical, you have to demonstrate that this machine is effective somehow. So we had a trial in an hospital, wrote an article about the effectiveness (or lack thereof) and did some paperwork. The idea is that you just have to demonstrate that it doesn't hurt. Of course, a physiotherapist will be twice as effective, but it's more expensive on an hourly basis, so that's why clinics love to buy the machine and just let patients sit on it.
I'm literally disgusted, but I can see everything around "medical" equipment having the same issues. All the economy surrounding hospitals, doctors and equipment is essentially broken, because there's essentially no competition, assured money (by the state in this case) and a lot of corruption going on within the clinics and medical companies (unfortunately).
What you describe sounds a lot like the problems the developed when supplying to government in general, whether it be IT, military, transport, etc. That said to me the US system sounds like it's so rigged that it has developed many of the same problems you encounter with government inflicted monopolies.
Medical equipment has to meet more rigorous standards. This reminds me of the news story where breast implants were being sold with low grade silicone in Europe:
I realise that suppliers are probably taking advantage due to limited competition, but at the same time, I hope the regulation helps to protect us from sub-standard products.
Are you sure you're looking at the whole picture? I imagine liability, lawyers, and a much greater interaction with customers will be driving up costs very substantially when selling widgets as medical devices.
Another case: I live in Poland and needed a knee surgery (arthroscopy). Costs:
-visit to a doctor and diagnosis (30$ per visit)
-MRI of a knee (135$)
-surgery + one day stay in private clinic (1k$)
So now I wanted to pay for everything without help of our health care system because that would mean waiting. When I tell people in US MRI costs 135$ in Poland they just can't believe it and this is in commercial clinic so they make money here, it has nothing to do with national health care system as I didn't use any refunds.
Do you mind if I ask where you went for such a cheap arthroscopy? I'm possibly in the market for this procedure myself, trying to weigh all the options.
People have mentioned the cost of MRI scans in the US.
How much would it cost to buy a bunch of scanners (full body, and bucket-type for arms and legs) and employ technicians to do the scanning and offer this as a service to hospitals?
You could have technicians working on shifts to have out-of-hours scanning.
The scans are provided in electronic format to the patient and to the doctors specified by the patient. The centre encrypts all the scans and stores them for X years to cover regulation and litigation.
There's a big capital investment cost, but you're not doing any actual medicine there (no interpretation of scans, for example) and so litigation risk is reduced. You can concentrate on churning people through the machines, you don't have to give way to emergency cases that need immediate scans.
And the price of a scan can be listed up front.
Is this a stupid idea? (Or is it already being done?)
You've framed it as consumer friendly but basically your hypothetical shop, on top of being another middleman, has gained a weak local monopoly on MRI's. That sounds like it's going to be bad for both consumers and hospitals which is why it would never happen.
As a sidenote the problem with MRI's isn't a lack of supply. A popular factoid a few years ago was that Pittsburgh had more MRI machines than Canada. Even if that was only half accurate it tells part of the story about high MRI costs.
I've posted about this a LOT here on HN, because I live in a country (Uruguay) that has a good level of medicine and prices are way cheaper (heart surgery as described would be at least an order of magnitude cheaper than in the U.S.).
One possible explanation I came up with was:
U.S. hospitals have legions of well-paid administrators doing paperwork for insurance companies, which will have legions of people doing paperwork on their side, and government doing its bit, and lawyers doing their thing. All that money is obviously not going directly into healthcare, it's basically monstruous bureaucracy friction. I suspect "real" healthcare costs, even factoring expensive U.S. doctors, would be shockingly cheap.
There are also other "hidden" legal costs, such as the cost of malpractice insurance, and overcosts due to doctors being extremely worried about being sued over malpractice and ordering unnecessary tests.
Is there a "transparent" U.S. medical institution whose expense records could be examined to come up with where all the money is going?
That said, the article compares with Ohio's Cleveland Clinic, which is the most famous heart surgery clinic. Supply and demand alone will make heart surgery there an order of magnitude more expensive, regardless of actual costs. But I've heard most U.S. clinics arent that much cheaper.
Maybe it would make more sense to compare it to prices in Europe or other places with similar medical standards.
My guess would be $100k in the US is about $50k in other places. At least my travel health insurence charges twice the rate if I travel to the US compared to "rest of the world".
First, adjusted for PPP that is more like $3,000. Second, nearly all personal and professional services cost way more in the U.S. Try hiring a nanny in India versus the U.S. and compare the prices.
In any case, whenever you talk about prices, it's important to try and think about it in terms of supply and demand. Why might prices for similar services be lower in India? In both countries, the price for that heart surgery is roughly the same order of magnitude as the per-capita income. But the median Indian is living far closer to subsistence than the median American. India's population is 70%+ rural and slightly over 50% are dependent on agriculture. Heart surgery isn't really an option for the median Indian.[1] While it may be financially catastrophic for the median American, between insurance, Medicare, Medicaid, etc, it is an option for the median American. The net result is that demand for heart surgeries, relative to the population, is far lower in India.
At the same time, the supply of doctors is higher. Being a doctor is considered socially desirable in India, and as a result there is a good educational infrastructure in place and plenty of candidates.
Higher supply and lower relative demand = lower prices.
I bet you can explain a lot about the U.S. healthcare industry in terms of regulatory issues, etc, but the magnitude of the impact of that is probably the difference between the U.S. and the UK, not the U.S. and India.
[1] It should be noted that when people give anecdotal reports about what things are like in India, there is tremendous perspective distortion. People will often pretend like relatively well-off people living in the cities are the "typical Indian" when in reality they're probably in the top 10%. It's as if the vast majority of India, poor and rural, doesn't exist.
Another thing to analyze is what's called "diseconomies of scale" where costs and/or prices rise with scale. Also many countries subsidize the health sector.
> Higher supply and lower relative demand = lower prices.
For manufactured goods and services that's not true in the _long run_. Higher demand will eventually bring down prices, and goods in low general demand will not see the innovation that brings down costs.
Can't resist posting this anecdote from Atul Gawande's (best known for his New Yorker medical pieces, such as the one about checklists) book, Better: A Surgeon's Notes on Performance...at the end, he describes spending some time in India as a visiting surgeon to see how innovation was possible in comparatively squalid circumstances. The Nanded hospital he describes below serves 1,400 villages, about 2.3 million people, with just 9 surgeons (Gawande says that'd be comparable to the state of Kansas having 9 surgeons):
note: It's a little OT, but I guess it's an interesting anecdote because it talks about how absolutely significant surgical innovation (not just, "good for the India masses") can occur in desperate situations. I have no idea if that applies to the state of the art of heart surgery in India.
------------
Among the many distressing things I saw in Nanded, one was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one patient with an ulcer so severe that the stomach’s acid had eroded a hole in the intestine. But Nanded is in a part of the country where people eat intensely hot chili peppers, and patients arrived almost nightly with the condition, usually in severe pain and going into shock after the hours of delay involved in traveling from their villages.
The only treatment at that point is surgical. A surgeon must take the patient to the operating room urgently, make a slash down the middle of the abdomen, wash out all the bilious and infected fluid, find the hole in the duodenum, and repair it. This is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes.
When I later told colleagues at home about the operation, they were incredulous. It did not seem possible. Motewar, however, had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment. His department was able to obtain some older laparoscopic equipment inexpensively. An assistant was made personally responsible for keeping it clean and in working order. And over time, Motewar carefully worked out his technique.
I saw him do the operation, and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.
I'm not gonna go on the conspiracy road but the world is functioning on the wrong parameters. Instead of being a united civilization and help each other in order to advance to a higher level, we are fighting each other like lions for supremacy in every domain possible.
Our whole system is based on superficial needs and wants rather than focusing on what we really need as species/civilization.
How can we expect innovation and progress when we can't even cross the damn ocean without selling our souls...we can't even cross our own borders without special rules. Not to mention that racism is high in many countries. We are divided as hell. If an advanced race would watch us right now they would probably laugh hard and leave.
190 comments
[ 4.4 ms ] story [ 211 ms ] thread"Need a heart bypass? We'll give you $10k and waive the co-pay if you do it in India"
1. People don't know about it.
2. Are the outcomes comparable?
3. Legal protection - you will have hard time suing Indian specialist in India and there won't be much damages to extract anyway.
4. Age? A good chunk of people that need that types of surgeries are well covered by Medicare.
5. You also need plane tickets, recovery time and at least one companion - so you may look at a lot higher total cost.
6. Plain old fear/ racism.
And the moment it becomes common there will be the full media smear campaign, scaremongering etc
However, ironically enough, the USA has a booming medical tourism industry also. At about 60-80k, it is only half as small as India (150,000), though nowhere near Thailand (1.42 million).
"...he has cut the price of artery-clearing coronary bypass surgery to 95,000 rupees ($1,583), half of what it was 20 years ago, and wants to get the price down to $800 within a decade."
This leaves me wondering: Where is the innovation toward affordable care here in the USA?
That's what competition in a free market is, no?
For most of the market, price competition does not occur because providers will not disclose the price of a service before selling it.
There is also an incredible amount of corruption surrounding drug prescription and diagnosis to get people buying way more drugs than they need to.
It isn't anything close to a free market. I could never open a health clinic out of my garage and put out a sign saying free anything related to medicine. By comparison, India has much more volatile healthcare (because they can't police everyone trying to play doctor) but get innovation as a result.
You got hit riding your bike and are bleeding profusely from your abdomen. The ambulance driver asks, "There's a hospital 6 minutes away but they don't post their prices publicly (who does?) and we've never brought anyone of your condition there before. We think it will probably cost between $500-$10,000. But there's a hospital 45 minutes away that we know for sure will cost $400-$800. What do you want us to do?"
Let's suppose the government mandates that all hospitals must post their prices publicly. But you're bleeding to death. Can you really go shopping now?
+ One business model is "Pay a flat fee of $50, cash on the barrel. Your kid gets to see a doctor in under 15 minutes. You know and we know that 98% of the time it's just your child being sick with a routine illness. We'll write the prescription if required and rule out anything more serious. If it is anything more serious, we'll explain your escalation options."
It's comparisons like these that really make you sick to your stomach. You don't see this kind of innovation in the American health system because it has been engineered with greed in mind right from the start. The lobbyist super groups, hospitals being paid kickbacks for using an exclusive medical equipment provider, the money hungry mentality of US medical corporations is more than obvious.
I think when your medical system becomes so expensive it's cheaper for people to fly out of the country, pay for accommodation and even some spending money to get the same level of care, if not higher than that of your own country, regardless of cost of living differences and other nation specific costs that's absolutely ridiculous. By the sounds of it, India is going to be the new global superpower if more and more people fly there to pay for medical treatment it benefits their economy in the end (given how a substantial chunk of the population is below the poverty line, this might not be such a bad thing).
A doctor trained in India is no less qualified than a doctor trained in the US. So expertise or training is no excuse either. In-fact I've found Indian trained specialists to be more thorough, careful, understanding and compassionate in comparison to that of Australian trained medical professionals (I'm from Australia). When was the last time you saw or heard of a poor American medical specialist or surgeon?
The question is: Will America ever change their ways? Or will quality medical care only be reserved for those who can afford decent medical insurance or have jobs that provide fair medical benefits?
One thing is for certain, this is submission is going to garner a lot of responses from both sides of the fence if past submissions along these lines are anything to go by.
In general?
http://blogs.worldbank.org/developmenttalk/shocking-facts-ab...
> It’s also pretty staggering that hiring qualified staff doesn’t appear to increase this probability. Das and colleagues suggest that part of the issue might be the variation in the quality of instruction in Indian medical training institutions. So there may be some institutions from which a qualification does make a difference. But given the paper’s results, the effect of such institutions must be rather small. The fact that providers working in better equipped facilities don’t have a higher probability of prescribing the right treatment is also alarming.
Obviously, heart surgery isn't rocket science, and our medical training is a bit overpriced, but is it so easy to compare two disjoint systems?
The difference between these two ends is incredible. While I can imagine these results at the latter, I find them hard to believe at the former. I'm paywalled away from this for the next two weeks, so if you want the facts, that's where I'd look: what sort of private healthcare.
Edit: To illustrate, another commenter has a link to an news story that says mortality is lower after the Indian procedure - http://m.theaustralian.com.au/archive/business-old/the-henry...
In any case, there is a difference between the general level of competency of doctors in a given country, and the level of competency available to wealthy foreigners travelling to the country for medical tourism.
There's something seriously wrong with both the healthcare system and the education system in US if the prices are 20x+ more than in any other country.
Careful here. I live in London for several years now, and from my experience Eastern European doctors are much better qualified then Western European. I'm originally from Poland, and medical studies are really hard, and people spend whole 6 years cramming just to become an apprentice to the doctor (it's Bachelors and Masters degree combined). On the other hand in western countries you can do undergrad degree in anything and only then apply to med school.
This was a few years ago though, from what I've seen the costs for eye lasering here seem to be catching up a little.
Frankly I'm a bit surprised by all the people in this thread saying "well that's a huge price difference, but how do you know Indian doctors are as good as US doctors"--as good? On what basis is the default assumption that US doctors would be better and the Indian ones need to prove themselves? All I know of the US healthcare system is that it's ridiculously overpriced, but just like that $8 bowl of ramen (wat) someone mentioned upthread, doesn't mean it's better, it might even be worse.
This isn't quite right. If you want access to anything but a fly-by-night medical school, they're wanting hard science and most likely a focus in biology.
Also, the 16 hour/day rule is only for interns, IIRC. Resident shifts can go up to 30(?) hours.
Anyway, you're drawing the wrong conclusion - it's astounding how close the US mortality rate is to the Indian, which attests to how good the US system is at operating successfully on more complex, elderly patients. Of course, you could argue that the US has optimised the wrong thing, at great expense...
Is that connected to the extra funding that older people get?
What happens if we compare mortality in people under 65?
Do centres that do more surgery have better outcomes? The answer to this is already a resounding yes. There isn't any doubt about that, it's been shown over and over again for multiple different surgeries within developed countries. Surgeons knows this, and so do health insurance companies. But of course this has to be asymptotic. Doing 1000000 CABGs doesn't make you 1000 times better than the surgeon that does 1000. So I doubt there is any real difference between the surgical skill in Shetty's centre and top institutions in the US. It's an untestable question in any case. The important point is that the care overall seems grossly non-inferior to the US, not that the US is inferior.
Within the US, the cost of heart surgery is highly variable, but if I were to go international, i would go south/central America over India any dry.
As a Indian (who comes from relatively simple background), I don't need a study to tell me that general/govt. hospitals that provide PHC are overcrowded, lack necessary support staff, lack necessary equipment.
What the bloomberg article is talking about is, another class of hospitals and medical staff. Narayan Hridayala, Fortis etc employ pretty good doctors.
I doubt that, any general statement can be made about - "doctors trained in India are less qualified than US", because it depends on lot of factors.
EDIT: Added "may be?"
In reality I think many healthcare entrepreneurs either get caught in the existing framework (and dependent on it), or find the regulatory and other hurdles too hard here.
That said, I still think there is a LOT of room to improve cost efficiency here, and the right entrepreneur could do it. It's been done in other stagnant segments of the economy... I would like to see an Elon Musk-type entrepreneur open efficient hospitals here like this guy is doing in India.
The opportunity is in helping Americans get real healthcare outside their borders. Take a glance Uber's way. You'll know you've got it right when there's serious talk about making it illegal to travel abroad to obtain medical care. For the safety of the people and the necessary good of the lowly American doctors, of course.
This sounds like a terrible law. Where can I look for more information on this?
Top it off with his worst payers were not the insurance companies but government based.
Government regulation, from deciding what insurance must cover for all people to not being able to shop across state lines was very much responsible for the rapid increase in healthcare. It didn't help much when we got sold out by Washington under the guise of Affordable Care to the drug, insurance, and hospital, companies. ACA was payoff for campaign contributions, that is why no one read the damn bill.
I'm not sure if you've heard the story but there is an American inventor by the name of Thomas Shaw. He invented the first safe, retractable syringe that was more reliable than any existing solution. Companies tried copying his design and managed only to produce sub-par copies, it's an interesting read. http://www.washingtonmonthly.com/features/2010/1007.blake.ht...
As an Indian, I can tell you people here think the same about our health care system. The Doctor in discussion here, Dr Devi Shetty is a sort of a local hero here in Bangalore. And who knows in some years he might as well be a national hero. Its basically because he seems to bring in advantages of doing things in volume + some health insurance based innovations into the whole equation. And I do agree that he is pragmatically altruistic. But such people are exceedingly rare. We are simply fortunate to have him.
I've never been to US, but I can tell you the Indian health care system is if not less is equally greedy compared to their US counterparts. Its just the same.
These days if you don't have health insurance you are more or less screwed. Its just like the US. I mean from whatever I've read about US so far its the very same. Nothing changes. You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x value of your money. That is what it is at the end of the day.
Coming to our system. Forget greed, fraud in the system is so massively high nothing that I write here will explain it. It is extremely common for doctors to order lab tests wholesale even if they are dead sure the patient has no problems at all. Doctors get commissions from testing labs/pharmacies etc for ordering lab tests, medicines. Treatment is purposefully prolonged, patients made to eat all kinds of antibiotics, undergo all sorts of non sense tests because doctors get commissions for it.
The fees for completing your medical course is astronomically high. Capitation fee often runs in crores, the net fee by the time you finish your MD is so high no doubt most doctors have to practically turn into crooks to get something out of it. Add to this nearly more than a decade of studies sets a perfect stage for these sort of activities to happen.
Its just the same old game, as you see in US. Just served differently.
I find the vast majority of people are tripped up by currency conversion, but I'm surprised to find this on HN. In Japan $1 = 100 yen, but certainly I don't feel I have 100x in buying power. A bowl of ramen will cost me $8 in SF; an equivalent bowl will cost me 800 JPY in tokyo.
Let's not even get started on the Korean Won...
Simply not true. Compare the cost of a beer in, say, Thailand and Norway. Are you suggesting if the exchange rate were fixed they would reach parity over time?
So in this case 60x is a reasonable assumption except not including the Purchasing Power Parity.
I have worked in both types of systems and can see merits and pitfalls in both.
In the former system there can woeful output whilst in the latter there can be woeful quality.
Neither of these are inevitable.
In a salary system, if the lazy/incompetent can 'get away with it' and the industrious/competent aren't acknowledged it has a poisonous effect on the organisation.
In a fee per item system the lazy will earn less automatically but there needs to be careful monitoring of the quality of the output with particular attention paid to people at either tail of the output distribution. Also people with high output (because of poor quality) can drive down wages for everyone and create a treadmill where the quality of everyones' work suffers as they try to maintain their income.
When I write a contract, there are often two prices: a minimum which is stingy and a bonus which is far from it.
The point is to say that if you do the minimum for this contract, you get a certain amount; if you excel, you get paid for that excellence.
Translated to health care, I think I'd like to see doctors doing less paperwork and more doctoring. It's not perfect, but I trust competition to pay that excellence price to those who deserve it.
That in turn means that if I need some kind of crucial care, I know where it can be found. If the system is over-regulated, that is not so.
I've thought about this a lot, and I don't think there is any objective way to provide outcome-based incentives. The best I could think of is peer-reviewed judgements of outcomes, but that could become pretty corrupt.
Get one and be safe, one serious illness can bankrupt you these days(actually it always has). But my point is even a week of hospitalization can be pretty expensive. And don't be under an impression you will be able to travel to Bihar or wherever when the need arises. During cases of emergency those are not practical solutions.
We recently had a baby (in Aus). Our Indian neighbour (been in au for 7 years) was amazed at how little medical intervention we had. His comment was that in India there was much more incentive to recommend drugs, c-sections, etc.
Its NOT the same. High costs in the US are essentially a result of policy corruption - a systemic issue with results in the exorbitant prices. Greed amongst doctors is prevalent in India as well as the US - maybe more prevalent in India due to general poverty. But health care in India is more 'free-market' than in the US, which is why it is more efficient.
>>I've never been to US, but I can tell you the Indian health care system is if not less is equally greedy compared to their US counterparts. Its just the same.
I have been to the US and I have spent a huge time in India. I have witnessed the Indian health system in close quarters and have close family members undergone major surgeries. There is greed in India, no doubt about it. But the American system is completely EFFED up - there is no comparison. If you go to the US and spend some time understanding/experiencing the system, you will be thankful for what you have in India.
>>These days if you don't have health insurance you are more or less screwed. Its just like the US. I mean from whatever I've read about US so far its the very same. Nothing changes. You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x value of your money. That is what it is at the end of the day.
You are completely wrong about this only because you don't know what happens in the US if you dont have insurance. My close family members have undergone major heart surgery at Narayanan Hrudyalaya. They had insurance, but even if the insurance did not cover it, it was not a big deal. I could have easily paid from my own pocket - it cost just over $2K USD - not a big amount for middle class Indians for life threatening surgery. All the prices are transparent - so if you dont want to pay as much you can choose cheaper options (shared post-op bedding etc.) which will reduce prices in half - with very little difference in medical care.
In the US if you dont have insurance for something like this - you will go bankrupt. The only reason you don't know about this is because most of your NRI friends work for bigger tech companies which provide good coverage.
Infact one of the reasons why health care is reasonable in India is because insurance coverage is limited and not mandated by law. The resulting free market delivers the economies quoted in this article.
>>Coming to our system. Forget greed, fraud in the system is so massively high nothing that I write here will explain it.
No it is NOT. There is a tendency in Indians to think that they are completely fucked up. Travel around the world - especially to the US and you will thank your stars - and please dont go with what NRI's say - they have a vested interest.
It is true that there is greed in the system and there is fraud - but there is a relatively freer market. You can 'choose' your doctors/hospitals. If you dont have a good experience with a hospital you can choose to write a review on Mouthshut.com and have them get less business. You can do your research and choose a better doctor/hospital over a worse one. This 'choice' and the enabling free market makes India health care deliver economies at scale which are impossible in the American system.
>>The fees for completing your medical course is astronomically high. Capitation fee often runs in crores, the net fee by the time you finish your MD is so high no doubt most doctors have to practically turn into crooks to get something out of it. Add to this nearly more than a decade of studies sets a perfect stage for these sort of activities to happen.
Assuming that this does turn them into 'crooks', they have an easy way to get their money 'out' - migrate to the US/UK after completing their residency. Some doctors are greedy, some are good. The greedy ones land up outsid...
You could have, sure easily! Besides a person who has traveled to US doesn't fall under middle class category anymore. Sorry you don't. In a country where kids die of hunger and where parts of the country manage to barely eat two rotis a day with salt- traveling and working in the US is a rich man's luxury.
Sorry to be putting it this bluntly, but in India anybody apart from Mukesh Ambani thinks he belongs to the middle class.
Most people(The middle class- People who make around 10/15K rupees a month) can't pay for expensive medical treatments, medication, post-op follow ups etc and that's a fact.
>> If you dont have a good experience with a hospital you can choose to write a review on Mouthshut.com and have them get less business.
Yeah right. I find it hilarious when techies offer solutions like these to common people who don't even know how to turn on a computer.
Mouthshut.com was just an example to demonstrate what it means to have a free market. My cook obviously can't access it - but he will ask me and his relatives on which doctor/hospital is good/cheap. He faces greater infomation assymetry - but the fundamental advantages of a free'r market still accrue.
http://natgeotv.com/za/scam-city/videos/delhi-doctor-scam
I am not sure it is true anymore. If you compare cost of living in a good infrastructure or similar lifestyle you will find India is expensive. I am sure many will disagree but just go ahead and look at cost of decent housing in any Indian metro. We too have crap doctors in India like anywhere else, may be they don't sound too expensive when you go by USD conversion.
... and even a few years of college tuition or a small mortgage ...
This might be objectively true (which you could reasonably determine through some combination of standardize testing and surgery complications/outcomes), but if you ask 100 people on the street in US whether they would prefer to see a US MD or an Indian MD for their heart surgery, I bet 97 or higher would prefer the US MD. The tiny remainder would probably show no preference.
Their is a brand power of a US medical education, which is especially strong for US patients.
That's what we should be asking IMO.
Well, the article says 2/3 of people live on $2/day, implying this surgery is $1600/$2/day = 800 days worth of work.
Taking the US median income of $45k (since I don't know the 2/3 number off the top of my head), that implies the equivalent price in the US would be ($45k/365) * 800 = $98,630. So, right about the same as at the Cleveland Clinic.
Per-capita income in India is $1492 Per-capita income in the USA is $49,922
So, it's around 1583/1492 = 1.06 years of work in India. And, 106385/49922 = 2.13 years of work in the USA.
And since the hospital price is actually 95k Indian rupees, exchange-rate fluctuations do not matter.
Chronically ill patients can still seek treatment, they may or may not be able to afford it though.
Perhaps you are correct, but I doubt this assertion. U.S. graduate schools are generally the best in the world, I am not sure why that should be any different for medical schools
First off, this article is comparing the cheapest clinic in India, with the most expensive and most revered Heart center (Cleveland Clinic) in the world. NH is basically like getting your heart surgery done at a non air conditioned WalMart. There are no patient rooms. There is a patient room. A giant room with beds lined up civil war style. The food is akin to gruel, ETC... Of course there is going to be a significant cost difference. This is like comparing staying at a Hostile and getting dinner in the soup line with Staying a night at the Hilton and ordering a New York steak dinner for room service, of course there is going to be a significant cost difference. Leave it to a reporter to compare the cheapest abroad to the most expensive here (a bit of stretching to make the store line a bit more catchy).
Second, the reported cost is false. "NH maintains its costs low, savings that are then transferred to the patient. NH's cost of open heart surgery is USD $2,000. The hospital charges $2,400 to the patient, compared to $5,500 charged at an average private hospital in India." http://healthmarketinnovations.org/program/narayana-hrudayal...
Third, the per capita income in India is $1,000 nominal dollars, in the U.S., it's $50,000.
So the average adjusted open heart surgery in India is actually $275,000 when converting to USD and comparing using the average per capita income. (Narayana Hrudayalaya's "discounted hospitals" only charge $120,000)
I know that the average income does not fairly reflect the true cost differential because India has a disproportionately large population of people living in abject poverty. It does make the cost difference margin quite a bit less though.
If you are wondering just how places in countries like this can operate more cheaply though? I will tell you. US laws. In America the law states that hospitals have to care for anyone even non citizens. It also puts stringent regulations on hospitals. Regulations that do not exist in India. These Regulations are very expensive to comply with.
Narayana Hrudayalaya's establishments are not hospitals, they are not for emergency care. They do not treat non-paying clientele. In America, our medical costs balloon out of control for many reasons, one of the larger ones being the care of non-paying patients. Emergency rooms and therefore hospitals cannot turn away patients for any reason. They must admit illegals and uninsured (even for long term care). They cannot recoup money from these individuals so the paying customers get to flip the bill so the hospital can remain in business.
Just try going to an emergency room in India as an illegal alien. You will be promptly jailed and deported. Try going without insurance or means of payment... Good luck with that (same MO as all these countries where these "cheap procedures" can be had)
There are some countries where these procedures are still cheaper than in the US and they cannot legally turn away illegals and uninsured. They have a slightly different formula. The government flips the bill (subsidizes the hospitals) thus allowing them to compete cheaply (which keeps the costs low).
My colleague _visited_ India and returned with a stomach flu, spent a week in a hospital.
[1] http://www.theaustralian.com.au/archive/business-old/the-hen...
I'm Australian, visited the US and got severe Salmonella poisoning in Vegas... the US must have really shocking road safety laws.
I am not sure, so I really would love to see the numbers/facts supporting your statement. Would love to learn of this magic fact. [cynicism end]
[Edit]: Typo
[Edit 2:] In Germany, with full health-insurance the cost for a Cardiopulmonary bypass are round about 30k €. So a lot cheaper, than in the US, despite health insurance.
Just wanted to present a fact, not let my comment stand as cynicism only.
Second of all, you ignore the incredible sums of money taken from the 'poor middle class' and handed over to the health industrial complex.
For most of this country's history [the USA], there was no such thing as health insurance. The poor got charity care and the middle class were able to pay.
Why do you think cancer treatment has to be expensive?
I wouldn't do this, because I do not have the necessary facts to make such a claim.
If a health-insurance system would work right, the health insurance agency might have a lot of more leverage in this highly regulated market, then any individual paying for its own. But that is just an assumption.
Well your next statement regarding my ironic "poor middle class" is just that: a statement, without any facts to support it.
I was asking for facts to support your statements. I even did some preliminary research into the costs of comparable healthcare in Germany (where I am from).
I just wanted to learn, if a "no health care" system might work better and be cheaper, but I will not just believe your statements, as that would just go against everything, I value.
So I really beg you, to show me verifiable facts substantiating your statements. Please?
That is the whole point of the mandate.
In particular, how do you account for the fact that more health insurance (Europe, Japan) is less constly than the abomination known as the US healthcare system?
... and people would start up health insurance again because it's absolutely needed. Silliest thing read on HN in weeks.
My country has a system that, while bad, sounds absolutely awesome compared to the U.S. . It's a socialist system that is called Mutualism.
The best explanation I could come up with after some Googling is: http://www.hmg.gov.uk/media/60217/mutuals.pdf "Mutual organisations do not have external shareholders - they are controlled by their members. Members may be users of the mutual, employees, other stakeholders or a combination of these Mutual organisations are either owned by and run in the interests of existing members, as is the case in building societies, cooperatives and friendly societies, or, as in many public services, owned on behalf of the wider community and run in the interests of the wider community"
http://en.wikipedia.org/wiki/Mutualism_(economic_theory)
It does have several downsides - mutual healthcare institutions are strongly discouraged from doing any healthcare on non life-threatening situations, waiting lists for surgeries are way too long, there's corruption and doctor bribing and queue-jumping and strikes... but it "works", most people have good healthcare and don't get bankrupt if they need surgery, for just about U$ 100 per month, and their families have coverage too.
PD: see also
http://books.google.com.uy/books/about/Mutualism_and_Health_...
I work in the medical products field and it's amazing how much distortion is introduced into the system when "insurance" is used to pay for everyday consumables. Products that go from RX to OTC drop 80-90% overnight.
A very simple plotting with data from wikipedia and rudimentary extrapolation, shows that more than 1.1 billion Indian's annual income is less than the current cost of heart surgery. India's total population is 1.2 billion.
Medical tourism, though very fine for a lot of folks who want a cheaper alternative, is driving up the cost of medical treatments in India by leaps and bounds. This makes surgeries, that were already very expensive and out of the reach of most Indian's even more expensive and out of the reach of even more people.
Sources: http://en.wikipedia.org/wiki/Income_in_India http://en.wikipedia.org/wiki/Poverty_in_India Simpel graph of the poverty data : http://imgur.com/JngiK8W (I used this to find the number of people with an annual income less than 1583 USD)
Any evidence to back this up? Your links and statistics are about how this specific cost is still out of reach of a lot of people. I don't think anyone is debating that.
> This makes surgeries, that were already very expensive and out of the reach of most Indian's even more expensive and out of the reach of even more people.
The article shows how the cost of surgery has dropped over time, and their goal being to drop it further.
One country was mentioned in particular (not India as it happens).
In Russia medical and other uni education free if you can pass entrance tests.
Let's go with the Indian bidder. What could possibly go wrong."
Is that actually what you meant?
He probably experienced a lot of difficulty initially in acquiring customers (who opted to go with the much cheaper, Indian consultants), which is why he has such an oversized Internet presence, including on Hacker News - it has helped build a brand for himself that isn't location-specific.
http://www.kalzumeus.com/2013/07/17/kalzumeus-podcast-5-quit...
A more charitable read of my old comments would be "The project(s) were beset by communication issues, terribly managed by the Japanese company (which, in the fine tradition of Japanese companies, I'll take blame for since I was unable to resolve it despite trying), and additionally undermined by pervasive competence issues."
I'm not talking my book here. In the first place, I don't have a book, as I no longer consult. In the second case, Indian BPO firms are less competitive with me than Chinese take out restaurants: our target customers are different, our projects are different, our marketing methods are different, etc etc.
In my case: U.S. cost structures, sure, I don't know them, though I do speculate and guess, and asked if someone knows of a hospital with transparent enough data.
Uruguay cost structures are a different bag altogether, since they're mostly government-run and they have to make numbers somewhat public. Add to that one of my brothers working in a hospital (he's a few years from graduating as a doctor) and other sources, and I can get an estimate that I hope is correct to an order of magnitude. A relative has been a customer of the Cleveland clinic, so I know the exact number he paid. I also know the exact number another person paid for the exact same surgery here in Uruguay - it was close to one-tenth, and he chose to pay private rather to go through the public institutions (which have huge delays).
Below is a PDF in Spanish, on an investigative piece from a weekly that goes into great detail on the costs of surgery in Uruguay. I'll just quote some basic numbers:
- Fixed fee per major surgery (medical act) UY$ 27.500 / U$ 1300
- Monthly Head Heart Surgeon salary (per hospital) UY$ 263.000 / U$ 12500
- Other heart surgeons, between UY$ 162.500 and 243.000 depending on seniority and other factors - U$ 8.000 to 12.000 range, per month. Those are close to the best salaries anywhere in Uruguay, usually as well trained as any doctor in the U.S.
- Cost to the hospital per major operation (heart surgery), UY$ 206.000 / U$ 10.000
Smaller operations like angioplasty cost UY$ 60.000 / U$ 3.000
The most expensive surgery is heart transplant, which costs UY$ 684.000 / U$ 32000
All those are set by the government, so those ARE the actual costs (well, actually they were in 2008, I didn't adjust by inflation and exchange rate), no insurance or strange stuff involved. The patient is not billed a cent, but there is a huge delay (months usually), and doctors don't really schedule surgery unless it's critical for the person's health (almost no quality of life procedures through the public system).
http://www.semanario-alternativas.info/archivos/2008/5)mayo/...
PD: Surgeons and Anesthesists have tremendous power, and managed to get paid close to ten times the rate of other doctors.
But back to the article, there are some U.S. healthcare costs that don't make any sense, I've seen procedures with firsthand accounts of an equivalent service here in Uruguay vs the cost in the U.S., and the cost in the U.S. is an order of magnitude more (and service sometimes much worse, this is the hospital I go to, try to argue it's worse than an average U.S. hospital ! http://www.hospitalbritanico.org.uy/ ).
Similarly, the company I work for regularly gets better software for one-tenth the price of U.S. bidders, we've bought local (Uruguayan), Colombian, Ecuadorean... it does help a lot that we know the language and how to do business there. It's not a hundred-to-one comparison as you mention, but there are huge market inefficiencies (in this case, they should be arbitraged away by someone selling services in the U.S., with a focus on quality and not devolving into Infosys or something).
Thanks to femto, we have some data. It seems that the 30 day mortality rate is lower than that in the US. Care to answer this other than with thinly veiled casual racism?
Dr Shetty's success rates appear to be as good as those of many hospitals abroad. Narayana Hrudayalaya reports a 1.4 per cent mortality rate within 30 days of coronary artery bypass graft surgery, one of the most common procedures, compared with an average of 1.9 per cent in the US in 2008, according to data gathered by the Chicago-based Society of Thoracic Surgeons.
Dr Lewin believes Dr Shetty's success rates would look even better if he adjusted for risk, because his patients often lack access to even basic health care and suffer from more advanced cardiac disease when they finally come in for surgery.
http://www.theaustralian.com.au/archive/business-old/the-hen...
Don't take this as part of any sides argument. All I want to point out is that the numbers you provide only paint part of the picture. Yes maybe flying to India for this one doctors procedure would be worthwhile but is it true across the board.
http://www.jayadevacardiology.com/procedure_charges.html
Alas I don't know how much the hospital takes, but I know that there are ~500,000 CABGs per year. I suspect that we as a nation are not spending $50 billion annually on CABGs, but I could be off.
There is a big problem with health care in most countries that I've been living into for extended periods of time (France, Italy and to a lesser extent Germany).
Anything sorrounding "medical" and/or "health care" has a 10x-100x price blowup, for absolutely no reason. I'm not even speaking about surgery, I can start by phisiotherapy consumables, such as elastic bands. Elastic bands are used in phisical rehab. They are dirt cheap, usually, if you buy them inside a child play store. But behold, if you buy the same stuff from "Thera Band", which is officially sold to hospitals and clinics, a couple of meters of the stuff will cost you 20-30 times more. I worked as an assistant in a phisical rehab clinic for several years, and this kind of bullshit is amazing, because it goes for everything (air balls, plastic rods for balancing excercises, and so on). The price inflation goes even higher with actual machines.
There is a machine which is called "Rehab 3xxxx" (produced by a clinic around here which I helped develop, so I won't disclose the details), which is just a linear actuator which moves back and forth. Literally, nothing more. There is an embedded controller which allows to tune the extension limits, and a couple of ABS plastic accessories that hold to the knee, wrist, etc.
The idea is just to move the articulation, and/or rotate it, over and over. You would think that there is something "fancy" about it, to name a few details which I wished this machine had:
* force feedback to stop the motion (right now the machine will just twist your arm as configured, no matter the force) * speed regulation (who needs it? just one speed is good enough) * some sort of patient-id so that you don't need to reconfigure it each time
But not really. Like I said, this is just a dumb linear actuator, with incredibly cheap ABS plastic accessories and a fancy name. Price? 30k euros in the basic kit.
The funny part: for anything medical, you have to demonstrate that this machine is effective somehow. So we had a trial in an hospital, wrote an article about the effectiveness (or lack thereof) and did some paperwork. The idea is that you just have to demonstrate that it doesn't hurt. Of course, a physiotherapist will be twice as effective, but it's more expensive on an hourly basis, so that's why clinics love to buy the machine and just let patients sit on it.
I'm literally disgusted, but I can see everything around "medical" equipment having the same issues. All the economy surrounding hospitals, doctors and equipment is essentially broken, because there's essentially no competition, assured money (by the state in this case) and a lot of corruption going on within the clinics and medical companies (unfortunately).
edit: english.
http://www.bbc.co.uk/news/health-16391522
I realise that suppliers are probably taking advantage due to limited competition, but at the same time, I hope the regulation helps to protect us from sub-standard products.
So now I wanted to pay for everything without help of our health care system because that would mean waiting. When I tell people in US MRI costs 135$ in Poland they just can't believe it and this is in commercial clinic so they make money here, it has nothing to do with national health care system as I didn't use any refunds.
How much would it cost to buy a bunch of scanners (full body, and bucket-type for arms and legs) and employ technicians to do the scanning and offer this as a service to hospitals?
You could have technicians working on shifts to have out-of-hours scanning.
The scans are provided in electronic format to the patient and to the doctors specified by the patient. The centre encrypts all the scans and stores them for X years to cover regulation and litigation.
There's a big capital investment cost, but you're not doing any actual medicine there (no interpretation of scans, for example) and so litigation risk is reduced. You can concentrate on churning people through the machines, you don't have to give way to emergency cases that need immediate scans.
And the price of a scan can be listed up front.
Is this a stupid idea? (Or is it already being done?)
As a sidenote the problem with MRI's isn't a lack of supply. A popular factoid a few years ago was that Pittsburgh had more MRI machines than Canada. Even if that was only half accurate it tells part of the story about high MRI costs.
One possible explanation I came up with was:
U.S. hospitals have legions of well-paid administrators doing paperwork for insurance companies, which will have legions of people doing paperwork on their side, and government doing its bit, and lawyers doing their thing. All that money is obviously not going directly into healthcare, it's basically monstruous bureaucracy friction. I suspect "real" healthcare costs, even factoring expensive U.S. doctors, would be shockingly cheap.
There are also other "hidden" legal costs, such as the cost of malpractice insurance, and overcosts due to doctors being extremely worried about being sued over malpractice and ordering unnecessary tests.
Is there a "transparent" U.S. medical institution whose expense records could be examined to come up with where all the money is going?
That said, the article compares with Ohio's Cleveland Clinic, which is the most famous heart surgery clinic. Supply and demand alone will make heart surgery there an order of magnitude more expensive, regardless of actual costs. But I've heard most U.S. clinics arent that much cheaper.
https://news.ycombinator.com/item?id=6077593
https://news.ycombinator.com/item?id=6019464
https://news.ycombinator.com/item?id=5763001
(I was really surprised by that one, why ARE ambulances so expensive in the U.S.?)
My guess would be $100k in the US is about $50k in other places. At least my travel health insurence charges twice the rate if I travel to the US compared to "rest of the world".
In any case, whenever you talk about prices, it's important to try and think about it in terms of supply and demand. Why might prices for similar services be lower in India? In both countries, the price for that heart surgery is roughly the same order of magnitude as the per-capita income. But the median Indian is living far closer to subsistence than the median American. India's population is 70%+ rural and slightly over 50% are dependent on agriculture. Heart surgery isn't really an option for the median Indian.[1] While it may be financially catastrophic for the median American, between insurance, Medicare, Medicaid, etc, it is an option for the median American. The net result is that demand for heart surgeries, relative to the population, is far lower in India.
At the same time, the supply of doctors is higher. Being a doctor is considered socially desirable in India, and as a result there is a good educational infrastructure in place and plenty of candidates.
Higher supply and lower relative demand = lower prices.
I bet you can explain a lot about the U.S. healthcare industry in terms of regulatory issues, etc, but the magnitude of the impact of that is probably the difference between the U.S. and the UK, not the U.S. and India.
[1] It should be noted that when people give anecdotal reports about what things are like in India, there is tremendous perspective distortion. People will often pretend like relatively well-off people living in the cities are the "typical Indian" when in reality they're probably in the top 10%. It's as if the vast majority of India, poor and rural, doesn't exist.
For manufactured goods and services that's not true in the _long run_. Higher demand will eventually bring down prices, and goods in low general demand will not see the innovation that brings down costs.
http://www.amazon.com/dp/0312427654
note: It's a little OT, but I guess it's an interesting anecdote because it talks about how absolutely significant surgical innovation (not just, "good for the India masses") can occur in desperate situations. I have no idea if that applies to the state of the art of heart surgery in India.
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Among the many distressing things I saw in Nanded, one was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one patient with an ulcer so severe that the stomach’s acid had eroded a hole in the intestine. But Nanded is in a part of the country where people eat intensely hot chili peppers, and patients arrived almost nightly with the condition, usually in severe pain and going into shock after the hours of delay involved in traveling from their villages.
The only treatment at that point is surgical. A surgeon must take the patient to the operating room urgently, make a slash down the middle of the abdomen, wash out all the bilious and infected fluid, find the hole in the duodenum, and repair it. This is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes.
When I later told colleagues at home about the operation, they were incredulous. It did not seem possible. Motewar, however, had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment. His department was able to obtain some older laparoscopic equipment inexpensively. An assistant was made personally responsible for keeping it clean and in working order. And over time, Motewar carefully worked out his technique.
I saw him do the operation, and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.
Isn't current consensus that chili peppers have nothing to do with causing ulcers, and may actually prevent them?
Our whole system is based on superficial needs and wants rather than focusing on what we really need as species/civilization.
How can we expect innovation and progress when we can't even cross the damn ocean without selling our souls...we can't even cross our own borders without special rules. Not to mention that racism is high in many countries. We are divided as hell. If an advanced race would watch us right now they would probably laugh hard and leave.