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.
>>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.
> 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.
> 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?
I've had heart surgery, costing very close to that six-figure the article gives. Every dollar was well spent. Tearing my chest open with a car jack, rendering me dead for most practical purposes, replacing body parts with cyborg components meant to last for decades, bringing me back to life, repairing the extensive damage caused, continuous monitoring for anything that could go wrong for a week, and sending me home in perfect condition save for a narrow scar, a daily pill and ticking like Captain Hook's crocodile - that's a heckuva process to go thru, it went spectacularly well, and I'm alive in great shape, heck yeah it was worth half the price of my house. They brought me back from the dead, how much is that worth?
"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."
Actually, it is not just the healthcare industry. All industries in capitalist societies are engineered with greed in mind, and that's OK. It works very well. The problem in the healthcare industry is not greed, but insurance. When someone else is paying for the care you don't care how much it costs. You don't shop around. This enables doctors and hospitals to charge more. American healthcare is very cost efficient where the care is not covered by insurance, for example plastic surgery, lasik etc.
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 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
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?
"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" - I wonder why this not happened on a large scale yet. It seems so simple - fly out stay for 10 days and get the surgery done, visit some exotic places such as the Taj Mahal and come back. Almost heart surgeries are planned, so planning is also not a concern. These days booking a flight in and out is a non-issue as is the issue of staying in a hotel. What's stopping people from adopting this on a large scale ?
>> 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 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.
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.
I would observe, that all of the "low cost" equipment and techniques that are being described here were developed by "greedy" corporations and hospitals in the USA (or possibly Europe). It's easier to be cheap when you don't have to fund any original R&D.
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).
Probably not going to get seen in this morass of comments, but I went back and reviewed the CMS data that the article cites.
The article used the Diagnosis Related Group (DRG) 238 - Major Cardiovascular Procedures without Major Complications. This is the best guess at capturing the costs of "Open Heart Surgery". (CMS only releases data for the top 100 DRG codes). "Open Heart Surgery" is a term for a variety of surgical procedures done on the heart, including valve replacement, vascular repairs of the aorta/vena cava/pulmonary vessels, and coronary bypass. These span a wide variety of DRG codes, including 216-221 for valve replacement, 228 (other cardiothoracic procedures with major complications), and 231-236 for cardiac bypass. Assuming we are comparing the operation known as coronary bypass grafting, then 238 is a decent enough code to use, with the proviso that it's not the best source for data.
Looking at the numbers claimed: If you download the Excel file from CMS [1], you can sort by DRG and Provider Name. Yes, if you search by DRG 238 and filter by Cleveland Clinic you will get $106,385 charged to Medicare. However, what the article completely leaves out (and anyone in medical practice will assume) is that Medicare simply does not pay the amount covered. Average Total Payments by Medicare: $26,898. That's how much Cleveland Clinic gets reimbursed, on average, by Medicare for any procedure included in DRG 238.
It gets more interesting when you include all providers and sort by average total payments. The highest average Medicare reimbursement to anyone for DRG 238 is $54,682; the lowest $13,233. Another interesting example:
In Alabama, at Brookwood Medical Center, DRG 238 covers $111,008 and only reimburses $15,552.
These comparisons of the US system to outside countries really need to compare average US reimbursement to their stated cost, because they sure aren't funding an army of administrators to get the insurance companies to pay up.
In summary, you can get "open heart surgery" in the US (Alabama) for "$15,552". I wonder what the Alabama price is if you walk in and offer to pay cash. If you can get it at the Medicare reimbursement rate, that compares decently to the Indian price.
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?
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."
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.
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.
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.
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.
His department was able to obtain some older laparoscopic equipment inexpensively.
Thanks to high-cost health care systems elsewhere spending enormous sums on the latest & best equipment on a regular basis, older equipment capable of facilitating very good (albeit not best possible) results becomes inexpensive.
In all the sneering at the high cost of healthcare in some areas, the consequential benefits to others gets overlooked. If you want the very best, yes it will cost a lot; if you're willing to settle for good instead of best, you can leverage what those buying the best paid for. If you cut the high cost options, the good low cost options may very well become infeasible.
> 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.
vs
> patients arrived almost nightly with the condition
It sounds to me like the limiting factor in innovation was a sufficient supply of patients FOR ONE SURGEON to practice on, in which case working in an underserved area is an advantage.
I think this is one of those cases where the proverb "necessity is the mother of invention" seems prescient.
It reminds me of physicians joining the military to work in battlefield condition because war creates the most interesting cases in terms of quantity and difficulty. Because you're in a triage situation, you can try out things where you normally wouldn't have a chance.
I'm curious what the innovation was here. Laproscopy is not new, and people are already pretty aware of its benefits. He applied it to a new operation, but is that innovation?
The only step that might have been innovative is, did he skip the washing out of the abdomen step without consequence? I'm inferring here, because it seems like that would be very difficult to do.
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?
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.
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.
- The hospital industry is a monopolized cartel - you usually need the approval of existing hospitals in an area before you can open your own.
- The insurance industry is a cartel - there are extreme compliance costs that only a few big players can take care of.
- Employer provided insurance is subsidized.
- Most 'reform' of health care in the US has punished individual insurance holders while strengthening the employment-based insurance system further strengthening third-party payment systems including increasing lists of 'must-cover' mandates for health insurance.
- McCarran-Ferguson act exempted health insurance from a competitive national market.
- The culture and institutional incentives in US healthcare push towards extreme capital-intensive expenditures and cut down on labor-intensive expenditures even when its not cost effective for the procedures that the patients require. Hospital beds get more expensive per day while extremely unlikely to succeed procedures like proton therapy expand further.
This paper is very illuminating and comprehensive: http://c4ss.org/content/2088. Please have a look even if you disagree with the solutions and the ideology of the author. I assure you it will be worth your time.
Let me also add licensing regulations that require MDs for routine procedures. Though nurse practitioners are becoming more involved and this is a good development.
Another issue which HN commenters are aware of is the AMA's cartel monopoly on medical school seats to control the supply of doctors.
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.
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".
This is over 94,000 Rupees. That is a huge amount of money in India. I'm not sure most people realize the cost of living difference between the two countries.
Case in point: I was in India (Chennai) for a week on business a couple of months ago. During that time (M-F), I had a driver who was dedicated to me. He took me to the office and back, and took me anywhere else I wanted to go. This wasn't a taxi service, he had nobody else to shuttle around. When I was working, he just waited around for me to call. The cost for all of this? US $25, for the entire week. That's what I paid the car service, so he's getting some amount less than that.
All this to say: These sorts of comparisons are not as dramatic as they seem.
That seems absurdly low. I stay in Chennai and typical taxi rates run upwards of 18Rs per KM (approx 0.48US$ per mile). I agree there is a considerable difference in the cost of living, but what you likely paid the guy was a tip for the entire week. Even assuming the car, gas etc. was paid by your company, the amount still seems low for a driver's fee for a week. My dad's driver makes 11,000INR a month.
94,000 Rupees is a lot of money in India but it is not so huge either. A small local doctor in a city will make around that money in a month.
(ps: If you actually had a guy driving you for 25$ in Chennai, do pass me his number. I will happily use him.)
$25 (approx. 1500 Rs by today's exchange rates) for car and driver for a week is implausibly low in a major Indian city. Depending on the particulars of the car etc, you could get this deal for a day or two, definitely not five.
[+] [-] DigitalSea|12 years ago|reply
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.
[+] [-] kamaal|12 years ago|reply
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.
[+] [-] losvedir|12 years ago|reply
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.
[+] [-] seanmcdirmid|12 years ago|reply
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?
[+] [-] ctdonath|12 years ago|reply
[+] [-] petilon|12 years ago|reply
Actually, it is not just the healthcare industry. All industries in capitalist societies are engineered with greed in mind, and that's OK. It works very well. The problem in the healthcare industry is not greed, but insurance. When someone else is paying for the care you don't care how much it costs. You don't shop around. This enables doctors and hospitals to charge more. American healthcare is very cost efficient where the care is not covered by insurance, for example plastic surgery, lasik etc.
[+] [-] danboarder|12 years ago|reply
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.
[+] [-] vasilipupkin|12 years ago|reply
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
[+] [-] vbuterin|12 years ago|reply
That's what we should be asking IMO.
[+] [-] deepGem|12 years ago|reply
[+] [-] andrewparker|12 years ago|reply
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.
[+] [-] solistice|12 years ago|reply
[+] [-] jfoster|12 years ago|reply
[+] [-] msonawane|12 years ago|reply
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.
[+] [-] ams6110|12 years ago|reply
[+] [-] smky80|12 years ago|reply
... and even a few years of college tuition or a small mortgage ...
[+] [-] bborud|12 years ago|reply
[+] [-] splintercell|12 years ago|reply
[deleted]
[+] [-] iterative|12 years ago|reply
[+] [-] goggles99|12 years ago|reply
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).
[+] [-] unknown|12 years ago|reply
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[+] [-] riahi|12 years ago|reply
The article used the Diagnosis Related Group (DRG) 238 - Major Cardiovascular Procedures without Major Complications. This is the best guess at capturing the costs of "Open Heart Surgery". (CMS only releases data for the top 100 DRG codes). "Open Heart Surgery" is a term for a variety of surgical procedures done on the heart, including valve replacement, vascular repairs of the aorta/vena cava/pulmonary vessels, and coronary bypass. These span a wide variety of DRG codes, including 216-221 for valve replacement, 228 (other cardiothoracic procedures with major complications), and 231-236 for cardiac bypass. Assuming we are comparing the operation known as coronary bypass grafting, then 238 is a decent enough code to use, with the proviso that it's not the best source for data.
Looking at the numbers claimed: If you download the Excel file from CMS [1], you can sort by DRG and Provider Name. Yes, if you search by DRG 238 and filter by Cleveland Clinic you will get $106,385 charged to Medicare. However, what the article completely leaves out (and anyone in medical practice will assume) is that Medicare simply does not pay the amount covered. Average Total Payments by Medicare: $26,898. That's how much Cleveland Clinic gets reimbursed, on average, by Medicare for any procedure included in DRG 238.
It gets more interesting when you include all providers and sort by average total payments. The highest average Medicare reimbursement to anyone for DRG 238 is $54,682; the lowest $13,233. Another interesting example:
In Alabama, at Brookwood Medical Center, DRG 238 covers $111,008 and only reimburses $15,552.
These comparisons of the US system to outside countries really need to compare average US reimbursement to their stated cost, because they sure aren't funding an army of administrators to get the insurance companies to pay up.
In summary, you can get "open heart surgery" in the US (Alabama) for "$15,552". I wonder what the Alabama price is if you walk in and offer to pay cash. If you can get it at the Medicare reimbursement rate, that compares decently to the Indian price.
[1] http://www.cms.gov/Research-Statistics-Data-and-Systems/Stat...
[+] [-] danboarder|12 years ago|reply
"...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?
[+] [-] patio11|12 years ago|reply
Let's go with the Indian bidder. What could possibly go wrong."
[+] [-] rayiner|12 years ago|reply
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.
[+] [-] kapad|12 years ago|reply
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)
[+] [-] GFischer|12 years ago|reply
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.?)
[+] [-] danso|12 years ago|reply
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.
[+] [-] ctdonath|12 years ago|reply
His department was able to obtain some older laparoscopic equipment inexpensively.
Thanks to high-cost health care systems elsewhere spending enormous sums on the latest & best equipment on a regular basis, older equipment capable of facilitating very good (albeit not best possible) results becomes inexpensive.
In all the sneering at the high cost of healthcare in some areas, the consequential benefits to others gets overlooked. If you want the very best, yes it will cost a lot; if you're willing to settle for good instead of best, you can leverage what those buying the best paid for. If you cut the high cost options, the good low cost options may very well become infeasible.
[+] [-] ArbitraryLimits|12 years ago|reply
vs
> patients arrived almost nightly with the condition
It sounds to me like the limiting factor in innovation was a sufficient supply of patients FOR ONE SURGEON to practice on, in which case working in an underserved area is an advantage.
[+] [-] Patrick_Devine|12 years ago|reply
It reminds me of physicians joining the military to work in battlefield condition because war creates the most interesting cases in terms of quantity and difficulty. Because you're in a triage situation, you can try out things where you normally wouldn't have a chance.
[+] [-] sliverstorm|12 years ago|reply
The only step that might have been innovative is, did he skip the washing out of the abdomen step without consequence? I'm inferring here, because it seems like that would be very difficult to do.
[+] [-] mistermann|12 years ago|reply
[+] [-] antiterra|12 years ago|reply
Isn't current consensus that chili peppers have nothing to do with causing ulcers, and may actually prevent them?
[+] [-] pravda|12 years ago|reply
[+] [-] ctrl_freak|12 years ago|reply
[+] [-] bluecalm|12 years ago|reply
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.
[+] [-] carbocation|12 years ago|reply
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.
[+] [-] tsax|12 years ago|reply
This paper is very illuminating and comprehensive: http://c4ss.org/content/2088. Please have a look even if you disagree with the solutions and the ideology of the author. I assure you it will be worth your time.
[+] [-] tsax|12 years ago|reply
[+] [-] nazgulnarsil|12 years ago|reply
[+] [-] swatkat|12 years ago|reply
http://www.jayadevacardiology.com/procedure_charges.html
[+] [-] yaix|12 years ago|reply
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".
[+] [-] larrywright|12 years ago|reply
Case in point: I was in India (Chennai) for a week on business a couple of months ago. During that time (M-F), I had a driver who was dedicated to me. He took me to the office and back, and took me anywhere else I wanted to go. This wasn't a taxi service, he had nobody else to shuttle around. When I was working, he just waited around for me to call. The cost for all of this? US $25, for the entire week. That's what I paid the car service, so he's getting some amount less than that.
All this to say: These sorts of comparisons are not as dramatic as they seem.
[+] [-] lewstherin|12 years ago|reply
94,000 Rupees is a lot of money in India but it is not so huge either. A small local doctor in a city will make around that money in a month.
(ps: If you actually had a guy driving you for 25$ in Chennai, do pass me his number. I will happily use him.)
[+] [-] chetanahuja|12 years ago|reply
[+] [-] joshmn|12 years ago|reply
[+] [-] randomtree|12 years ago|reply
My colleague _visited_ India and returned with a stomach flu, spent a week in a hospital.
[+] [-] socialmediaisbs|12 years ago|reply
[+] [-] firefoxNX11|12 years ago|reply