Obamacare is the law of the land


And what is the deal with department stores? I walked into one the other day and they had a pair of shoes for $170. But shoeguy1975 had the exact same pair on eBay for $120 with free shipping!

Here is the thing: you can reduce costs if customers are willing to wait a few days and get their product in the mail. Amazon and other companies built their businesses on this principle.

Insurance companies want to save money too. Mine won’t let me fill my prescription at a drug store any more, I have to wait for it to be shipped. And still they want to save more money. So, are you willing to wait a few days for orthopedic products? I have a feeling that we’ll find out soon enough. But expecting a doctor’s office to price match an online retailer is as unrealistic as expecting a small boutique to price match Amazon.


But but but FREE MARKET!


Again, this is an inapplicable analogy. The price of the pneumatic boot had absolutely nothing to do with how willing I was to wait for it, and I have no idea where your Ebay comment is coming into it. The point of my comparison is that if I can purchase a single piece of brand new medical equipment from a certified medical equipment supplier (not Ebay) for a $120 flat cost, a hospital or orthopedic doctor’s office should be able to purchase the exact same piece of equipment at a lower cost because chances are good they are not paying retail for it and they’re ordering in bulk.

I’m not saying some amount of markup isn’t applicable, but to then mark up that same piece of equipment to nearly FOUR TIMES their own cost…why? Simple, because:
A) Captive market…you want that boot today, right now, because the doctor says you need it.
B) Price blindness…you have no idea what the real cost of that boot is, or what he will bill you for it, or what the insurance company will decide to pay or not pay. This creates an opportunity for enhanced profit at the consumers expense. How many people actually go out and research the cost of their medical device AFTER they’ve purchased it, had it implanted or whatever? Very few. So the system continues unchallenged.

I mean, I’m sorry, but if you can’t see how that is a system designed to fleece it’s consumers, then I’m not sure how better to explain it.


Here’s the thing: If you want to pretend that medical expenditures are like other consumer expenditures, you can do that, but no one has to take you seriously, and few will.


Medical products, like other products, benefit from economies of scale. Even if you wished they didn’t.

You can try to come up with a system that mitigates this effect, but that system doesn’t exist yet. So don’t act so surprised if right now you can find a good deal online for your meds, contact lenses, orthopedic boots, or anything else.


No one disputes that. You’re just flinging dung. That’s the point.


Yes, that is precisely the dispute. The argument is that an orthopedic boot bought in a doctor’s office is priced too high, because it costs much less online. But everything costs less online, so that’s not much of an argument.

You could argue that the boot should cost more than it costs online, but less than what this doctor charged. But unless you have access to the financial records for this clinic, it’s just idle speculation. For all you know, they are barely breaking even on the boot. Markup isn’t profit.


Yes, it’s totally unknowable, because no one in any other country with any other system ever sells medical products or services, so we simply have nothing with which to compare our own prices to theirs.


Yes, because the only difference between a doctor in the US and a doctor in another country is the price they charge for boots, so we can safely assume that all their other costs are exactly the same.


It’s a complete and utter fabrication that healthcare in the United States is somehow so much more amazing and advanced than healthcare in other nations. People in Japan, Italy, the Netherlands and other first world countries have quadruple bypass surgery and heart transplants every single day and the only difference between their care and ours is the bottom line cost.


That’s not what I meant. Even if the quality is the same, the costs are higher. Costs not only to the patient, but to the physician. Whatever your doctor paid for the boot is likely more than in other countries. Likewise support staff and other operating expenses. So you can’t simply look at the bottom line and conclude that he ripped you off.


Except I can, because multiple American suppliers sell the device for $X, and the American doctor charged me 4 times X, with the full knowledge that my American insurance company would knock that down to 1.5 or 2 times X, and everyone would make money along the way.

Is it the doctor’s fault? NO. His office is only doing what the entire system has been designed over time to do. He’s not going to be able to change things all by himself. The fault lies within the system, which was the point all along. We need a single payer, controlled cost healthcare system. Various posts in this thread have put forth ideas on how that might be accomplished, but the bottom line is that the system we have now is designed to fleece the consumer, and it only continues to get worse. It’s unsustainable, and barring an earlier than expected total collapse of the Social Security system, will be the biggest challenge the country faces in the decade to come as more and more people are priced out of healthcare entirely.


This sounds like someone grumbling about MSRP on Amazon. “$60 is way too high for an SD card!” And then you pay $34.99 at checkout just like everyone else.

Yes, everyone expects a discount at checkout. And so the “original price” is marked up with the expectation that it will be discounted later. If you’re drawing conclusions from the price you didn’t even pay, then you’re missing the point.


Except Amazon doesn’t charge each person who buys that SD card a different price between $14.99 and $75 depending on what ISP they’re using and what level of service they are paying that ISP for each month.


First of all, you don’t really know how much all the other patients paid to pick up a boot at your doctor’s office.

Second of all, patients don’t just buy boots. It’s possible they paid a lot more for the boot, but a lot less for meds. Or everything cost them more, but they saved money on premiums. To some extent our current health care system encourages this sort of horse trading.


What you mean is that it’s not possible to know that health care products and services in the US are overpriced. That’s nonsense, no matter what sort of clothes you dress it in. It’s not a serious view.

This is a great example. Lots of people have compared US health care costs with other countries and found that the US is far worse off. Can you point to one such comparison which shows that the US is better off thanks to this wonderful encouragement of horse trading? I’m almost certain the answer is ‘no’, but go ahead and surprise me.


No, they are definitely overpriced. But it’s impossible to know the doctor’s profit margins on retail boot sales. So I see no evidence to blame his pricing policy. Perhaps his markup is excessive, but it’s equally possible that his retail profits are slim and your money actually ends up in other hands.

This wonderful encouragement of horse trading is how our elected representatives want to pay for health care. It’s certainly not a system dreamed up by the orthopedic surgeon you’ve targeted. You want to point a finger, then point it at voters.

The US system is great for patients who want doctors to try everything that might possibly help them, even a little.

To take a random example, consider the treatment of glioblastoma. This is the uniformly fatal brain tumor that killed John McCain. In the US, about 70% of patients receive surgery+chemo+radiation and only 1% go untreated. In Taiwan, only 50% of patients receive surgery+chemo+radiation and 10% go untreated. And in the US, treatment options include newer chemo agents that aren’t available in Taiwan.

Patients who undergo surgery or get the latest drug might live a little bit longer, but the disease is terminal regardless. And glioblastoma patients are usually elderly to begin with, a few extra months of life is lost in statistical noise when you look at the overall health of Americans and Taiwanese.

Neurosurgery (often multiple rounds) and the latest drugs are very, very expensive. So is it worth spending a lot of money to buy just a little extra time? Your answer likely depends on whether you live in the US or Taiwan.

EDIT: Another example just popped into mind. In the US, annual screening mammograms are recommended for women as young as 40. In France and Germany, mammography is recommended biennially, starting at 50. In the UK, it’s every three years for women over 50.

Who is right? Depends on whether or not your goal is to detect as many cases of breast cancer as possible. Because the last one you detect will be far more costly than the first one.


The US certainly abuses defensive medicine (overtesting). In this case, for example, incidence-adjusted breast cancer mortality doesn’t seem to be different between the US and France or Germany (France has higher mortality, but also quite higher incidence). Probably has to do with the fact that, although less frequent, mammograms in France are free, so less people will decide against following advise.

Also, annual X-ray mammograms can pose risks long term, specially if started so young. I’m no expert, but I doubt it’s mainly budgetary reasons why standards differ between countries. Edit: It’s actually based on US recommendations (I don’t know where you got your annual, starting at 40 data, because that’s really aggressive and might be recommended only for high risk individuals).

It’s a difficult issue (I’m certainly high-risk for certain health issues due to family history and will begin periodic testing at 40, so I’m certainly not against screening), but overtesting and overdiagnosis is a problem that props up more under private healthcare systems.


None of your examples are responses to the question I actually posed, which you for some reason mangled.

In response to a claim that medical costs in the US are too high, you wrote:

Now, maybe I don’t understand what you’re getting at, but it seems to me that you’re saying we pay more for some things but less for others so that on balance it’s not really clear we actually pay more.

So I wrote this:

Note that I explicitly asked about costs. It seems to me that you’ve largely ignored costs to talk about efficacy instead, and that you’ve separated the two parts of my last sentence so that they are disconnected, and that you’ve responded to them in the opposite order, so as to effectively answer questions I didn’t ask.


No, I stated at the beginning that I think it’s clear at pay more. The issue is whether this doctor is contributing to the problem or merely responding to a problem elsewhere. And I said you cannot determine that by looking at a single price, for several reasons. One reason is that prices are not independent of each other.

Since I explicitly answered that, twice, I assumed you were asking about something more interesting. Like what exactly are we getting for our money.

Those are the new USPSTF recommendations. They differ from the American Cancer Society and other societies. It’s not just age, it’s also the screening interval.

Annual starting at 40 has long been the recommended schedule in the US. The new USPSTF recommendations have proven quite controversial. They came out around the time of the ACA debate, so there was immediate public suspicion (not necessarily fair) that they were motivated by cost.

But they are also based on the belief that not all breast cancers need to be detected early. For young women in particular, breast cancer can be so aggressive that treatment is futile even when detected early. Similar reasons motivate the change to biennial screening: cancer that grows fast enough to be detected after a short interval is also much more likely to prove fatal.

There are other considerations behind screening schedules that I won’t bore you with. But imagine you are a doctor with a 41 year old patient who wants a mammogram because her best friend just died of cancer. The USPSTF wants you to decline to offer the exam, and tell her not to worry about it because if she really has cancer at this age then she will probably die regardless. Which is true. But you can imagine the response.