High Deductible? As Doctor: Here’s what Doctors Can do to Save You Money. Hospitals, Health Insurers Hate it

“Just tell me the effing price.”

By Michael Gorback, M.D.:

“There’s something happening here. What it is ain’t exactly clear.” — Buffalo Springfield, “For What It’s Worth.”

Dateline 2000. You go to the doctor. At the end of the visit you are asked to pay your co-pay. The doctor files a claim with the insurance company for the rest. You might not even have to pay the co-pay at the time of the visit if you have a naive doctor who is unaware of how many people don’t pay their bills.

Dateline 2016. You go to the doctor. After the visit you have a discussion as to whether you want to use your insurance or pay cash (actually credit card, etc., not cash-in-fist).

That’s different, to say the least.

In days of yore, insurance paid a high percentage of the costs. After the advent of managed care, many people figured a doctor visit cost $20 or so. Insurance covered most of the fee, and the patients were blissfully ignorant of what medical care really costs. You could get a one month supply of medication for a co-pay of $10-20.

In recent years, we have evolved a system where deductibles have risen in order to keep premiums from rising. This allows employers to offer health insurance at lower rates, with the cost being passed to the employee. After a certain point, rising deductibles turn everything upside down.

High deductibles have rendered many people functionally uninsured for the first several thousand dollars of care every year. Whereas 10 years ago, your share of a $500 surgeon’s bill might have been $50, now it’s $500 unless you’ve met your deductible to the point where at least some of that $500 is covered. Even then, there’s often coinsurance after the deductible has been met. You could still be on the hook for 30% of the $500.

Unfortunately, the medical profession has not kept pace with what’s happened, nor is it equipped to deal with it. Like negative interest rates, this is new and hard to conceptualize: cash (credit card, etc.) might be better than insurance. In the past, doctors preferred insured patients, and it was best if they had private insurance. Nobody was thrilled about Medicare.

In response to the functionally uninsured, various fragmented approaches have been tried. Now we have concierge and other forms of cash practices that bypass insurance. This can work for practices with low patient costs, like family practice. It won’t work for a heart surgeon. Nevertheless, cash payment is on the rise.

Here are three stories from just the past two days:

  1. I had a patient who needed an MRI. The facility where I sent her was in-network with her insurance, but the contracted rate was over $1,000 and her deductible was $3,000. I knew that this facility had a cash rate of less than $500. My advice? Don’t use your insurance. Pay cash.
  2. I emailed this story to an acquaintance who related a similar story. His daughter saw a doctor who recommended a procedure that would cost $450. When she said she had a high deductible, he recommended the cash price of $195.
  3. I mentioned the above stories to an anesthesiologist this morning in the O.R. He told me he went to have blood tests done and the projected cost was $400. When he mentioned his high deductible, they offered him a cash price of $99.

What does this say about the burdens of dealing with insurance companies that the providers of these services are willing to discount so much for cash?

And here’s another story. It shows there are parts I still don’t understand.

I had a patient who needed a Synvisc One injection. His insurance company insisted we use their specialty pharmacy, which quoted a price of $1,200, which is the full-pop retail price at a retail pharmacy. My cash price for an x-ray guided Synvisc One injection — drug, x-ray guidance, and my professional fee — is $787. The patient had a large deductible, and we just couldn’t understand why the insurance refused to allow him to get the lower price. Finally after drilling through several layers of bureaucracy, we got someone to approve it. It seems somebody’s getting a kickback somewhere. I think there’s something very crooked about the whole Pharmacy Benefit Management business.

I can tell you some of the things I like about cash (credit card, etc.) payments:

  • First and foremost, the only decision makers are the patient and me. There is no game of “Mother-May-I?” with an insurance company.
  • If I can provide the service in my office and not use a facility, I can provide a 100% accurate cost estimate.
  • We don’t have to delay treatment while we wait for authorization. I can see you in the morning and do your procedure in the afternoon. The patient with insurance often has to wait while we get the OK from the insurer.

Transparent cash pricing is uncommon among hospitals. I know of a handful of facilities that disclose prices, among them the Surgery Center of Oklahoma and Houston Physicians’ Hospital (where I am one of the founders and a current shareholder). Both facilities offer package deals that include the surgeon’s fee, the O.R., and the anesthesia. Even then, however, there are considerations that can’t be packaged because different hardware implants have different costs or further testing must be done.

Note that the more transparent facilities like Surgery Center of Oklahoma and Houston Physicians’ Hospital are owned and operated by doctors. The government doesn’t like physician-owned hospitals, and there has been a moratorium on new hospitals or expansion of existing hospitals for about a decade. Perhaps they think doctors don’t look out for your welfare as well as politicians and career bureaucrats.

Congress prefers non-physician hospital owners like HCA, which paid out over $2 billion for Medicare fraud. Rick Scott, the Chairman and CEO at the time, did not go to jail. Instead he left with $350 million in stock and $9.88 million in severance pay. He then went on to become the Governor of Florida.

Or Tenet, which has paid over $1 billion in penalties and legal settlements for fraudulent psychiatric admissions, unnecessary heart surgeries, and Medicare fraud.

Before we schedule a procedure, my staff goes online and checks benefits (deductible, how much unmet deductible, coinsurance, etc.) and runs the numbers. We then give the patient an estimate of their out of pocket expenses for my services. We have a standardized work sheet that we give to the patient so they can follow the calculation.

Imagine trying to do this calculation yourself every time you needed expensive care. How many people know how to do that? How many medical practices and facilities have transparent cash pricing? The answer to both questions is “not many.” I instituted cash pricing for my practice on the Internet in 2014 at directpaypain.com, and I have not raised the rates since then.

I can give you an accurate estimate of the cost of a procedure done in my office because I have total control over the process. I can’t control what hospitals, anesthesiologists, radiologists, etc. will charge. Houston Physicians’ Hospital will call my patients before their surgery with an out of pocket estimate for the facility charges. This is rare. It also prevents unpleasant surprises.

Most hospitals will not give you a cost estimate. If they do, you’ll get a quote based on the ChargeMaster, which is sort of like MSRP for a car – it’s much higher than people end up paying. However, unlike MSRP, the ChargeMaster is often astronomically higher than the true final cost.

Somehow, as if by magic, on the day of surgery, they will suddenly know what your out of pocket cost will be. You register and they tell you they need $1,500 before you can proceed. Unfortunately, that’s after you’ve taken off from work, plus a day or so for recovery, and maybe the person who is transporting you back and forth has taken time off as well. It’s hard to walk away at that point and comparison shop.

I don’t know how many of my colleagues provide cost estimates. I think there is still a fair amount of old style thinking regarding insurance. Practices don’t seem to understand that we have evolved into a system where many patients are functionally uninsured until they meet their deductible, which is often several thousand dollars. The fact that it’s often better to pay cash is a new wrinkle that we’re adjusting to.

To complicate matters, if you go the cash route it doesn’t apply to your deductible.

Every medical practice and facility that accepts insurance has the ability to provide realistic cost estimates. It’s time they started. Given the wide disparity among third party payers, it may not be feasible to advertise prices, but surely if my little solo practice can provide estimates based on analysis of benefits, so can they.

Competition on pricing usually reduces costs, but since the hospitals refuse to disclose costs, there is really no competition. They might compete for doctors to use their facilities, and they might compete for patients with advertisements, but they don’t compete on price.

Ads for hospitals talk about caring, they talk about quality, they talk about how US News & World Report ranked them #1 within a 500-foot radius, and there are usually several smiling people in some sort of medical garb from diverse ethnic groups. They talk about everything except their prices.

The only entities that consistently advertise prices are cash businesses such as Lasik. The CEO of the Cleveland Clinic has been quoted as saying they won’t reduce prices due to transparency because they will compete on quality. It would be interesting to test that hypothesis with a truly transparent pricing system. The market might hand them an unpleasant surprise.

As Americans continue to pay an ever-increasing share of their medical costs, the ability to do comparison shopping through a transparent pricing system would help immensely and is highly likely to reduce prices. By Michael Gorback, M.D., board-certified in Anesthesiology and Pain Medicine. He practices pain management at the Center for Pain Relief in Houston, TX.

Buying a home has been an effective way for foreign residents to launder some money and get their wealth out of harm’s way. In the trophy markets on the US West Coast and in Canada, rumors of a massive influx of Chinese money have formed a crescendo. In Vancouver, 33% of sales are to Chinese investors, according to a new estimate by National Bank. Read…  Desperate Chinese Investors Flood US, Canadian Housing Markets, But Real Numbers Are Taboo

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  138 comments for “High Deductible? As Doctor: Here’s what Doctors Can do to Save You Money. Hospitals, Health Insurers Hate it

  1. George says:

    Hey Wolf, I love your musings on finance and the global ponzi scheme. Here is another example of cash money benefitting health costs. As you know kids need a check up before starting school in the late summer/fall. So one of my kids had been left uncovered, my fault. So I receive the bill for $900, man I was sweatin’ that. I attempted to get it retroactively covered, no luck (that’s a shocker). When I got my Christmas bonus I went to the doctor’s office with $600, asing if I could settle the bill out of pocket? Sure give us a minute, she comes back with a $75 bill. You are spot on with this one Wolf!

    • Wolf Richter says:

      Thanks, but I’m not the author. This was written by a doctor who knows, Michael Gorback, who also comments on this site. I’m not smart enough to write these sort of things.

    • Harvey says:

      Why not work to enact Improved Medicare for All HR 676 aka single payer?
      You can treat anyone who comes, simplified billed, no collection problem,less overhead, no patient drop out of treatment due to lose insurance, etc etc.!

    • TheDona says:

      Shop around for your kids needs. The Doc in the Box venues (Prima Care, Urgent Care, etc.) do a $35 back to school checkup. High Schools in my area will do a $25 checkup (they have Doctors brought in) but the wait times are horrendous. Free back to school vaccines (promoted by city and county) at the malls…but long wait times. Look up some of the county clinics as they provide $10-$20 dollar vaccines and surprisingly there is low to no wait time. I learned all of this from an elementary school teacher who knew how to stretch a dollar.

      State Colleges provide a variety of medical services for free…payed for by part of the hefty tuition fees. They even post the prices of extra services. EKG is $42 and Chest X-ray $54. Consultation by an MD is free and most meds are too.

      We have been using the same Doctor at the Doc-in the-Box for 15 years. The most I ever spent there was $350 (cash price) for multiple stitches in both shins. That price included irrigation, tetanus shot and antibiotic treatment. Price seemed reasonable to me. I am guessing it would have been 2 or 3 times that a private practice and 10 times that an an ER. If your kids are in sports you will most likely have a few stitches, broken fingers or sprained ankles along the way. For these minor injuries this is the only affordable way to go.

  2. Petunia says:

    I’m one of those people with really good insurance who can’t afford to go to the doctor. The insurance companies are definitely gouging the patients but the doctors do so as well. How many times have you gone to a doctor only to be referred to all his “friends” for further testing? For most of us, it is all the time.

    I like the idea of not having the insurance company between the patient and the doctor and I am also old enough to remember when that wasn’t the case. But, even then if you didn’t have the money you didn’t get the treatment. We need a single payer system because I don’t trust the medical industry to take care of me without oversight. If it wasn’t for the competition from overseas, which seems to be cutting into their incomes, most doctors wouldn’t care about the costs to the patients.

    • Colorado Kid says:

      Competition from overseas is also affecting the dental industry. I recently needed a lot of dental work done (my entire mouth is now filled with crowns) and when I asked my dentist about the quality of work in Mexico, we had a long discussion. She did not badmouth all Mexican dentists, but did tell me about a couple of people she had to refer to oral surgeons because they’d been so messed up. I went home and did extensive research and decided not to go, based on a number of horror stories and also the logistics of going, and when I returned to her office, she gave me 20% off for cash. She’s known as the best dentist in this area and has lots of patients, so I was surprised.

    • Michael Gorback says:

      Petunia, I really wish you wouldn’t paint all doctors with the same brush. As in any field there are good and bad, smart and stupid. I resent the implication that I am gouging patients by making referrals. In my field I often need input from neurologists, spine surgeons, rheumatologists, etc. Perhaps you are mistaking prudent medical practice as some bizarre conspiracy.

      • Petunia says:

        Dr. Gorback,
        I wish I had something nice to say about your profession but I don’t. I think doctors will do anything for money.

        Twenty years ago I got a call back on a pap test, per-cancerous cells, they said I needed a hysterectomy immediately. I went for a second and third opinion, one agreed, one disagreed. They all thought I should have the surgery anyway. I decided to wait and see and I am still waiting. I have even worse examples than this I could cite.

        Very recently, my son need his wisdom teeth extracted. One doctor said he needed to remove another tooth too. We went to another doctor who only removed the 4 wisdom teeth.

        My general opinion is that doctors will do anything for the money, whether it is medically necessary or not. I think most breast cancer surgery is totally unnecessary. I base this on the statistics of breast cancer in America over other countries. They do it for the money.
        If cancer treatment was less profitable there would be a lot less of it in America.

        • Michael Gorback says:


          Yes you will get different opinions from different doctors. That’s because very few conditions have a single unquestionably superior approach. Doctors have been refining breast surgery for decades. When I was an intern the treatment was radical mastectomy, a very disfiguring procedure. Then some of those oh-so-evil cancer doctors tried things like simple mastectomy, lumpectomy and so on, with or without chemo or radiation. Damn those horrible people! How dare they come up with less invasive procedures?

          Our President thinks a lot like you. He thinks ENT doctors are fee-hungry tonsil miners, even though the medical profession developed criteria that reduced the number of tonsillectomies years before he made his idiotic remarks. He also didn’t understand that in many cases treating chronic recurring tonsillitis costs more than a tonsillectomy, plus missed school days and other social consequences.

          Meanwhile, fight the good fight. Keep those cancer bastards from getting your money. Refuse to have a mammogram or screening colonoscopy. If you find a lump in your breast or develop rectal bleeding do not seek medical attention. Go to Mexico and get shots made from monkey glands instead like they advise you in your subscription to the National Enquirer.

          I will happily leave you and Mr Obama to your ignorance and paranoia, and sleep better knowing that there is no way in hell that you would ever consider seeing me as a patient.

      • Colorado Kid says:

        I’ve known many doctors, as I once owned a medical publishing company and contracted out a lot of the writing with specialists. My experience has been that most docs (and this includes those when I was the patient) are caring and competent and overworked. I did once have to fire a doctor when he put my elderly dad on meds that were contraindicated – found out he’d had a number of malpractice suits – but that’s rare.

        I think the pharmaceutical industry has had a very negative impact on the perception people have of the medical industry in general, as people think docs are paid to push drugs. Some are, but many are very caring people. A lot of the good docs are retiring and leaving the biz because of the paperwork and costs of malpractice insurance.

        • Paulo says:

          From Canada, here….single payer system. Less money spent per capita and better outcomes. BUT…sometimes you do have to wait as they triage the care. Elective surgery takes back seat to emergencies and you may get bumped. I have known people waiting in the operating room for a knee operation when car crash survivors are wheeled in. Guess who got operated on first?

          I had cancer and my family Doc found it on a routine physical. First, an ultra sound…then CT Scan…then a visit to the oncologist with surgery in less than 1 week from diagnosis. Stopped in Stage 1, and I am now considered cancer free and being released from a 10 year surveillance program after 5 years. Why? Because they caught it so early. (Although, I plan to sneak in marker blood tests through my GP).

          Single payer is the way to go. I love my Doctor. His professionalism and skills changed my life and that of my family. Every visit I bring him a bottle of wine and some smoked salmon. I see him just once per year for a checkup.

          I wouldn’t be a doctor, nor could I be. I really do not believe I could tell someone they were going to die or their child was ….whatever. I don’t think I could do it. Plus, they work extremely hard for their money, here in Canada.

          When I saw the surgeon and he said I needed immediate surgery I was floored and astounded. My words: “With all due respect, do you think we are being a little hasty here”?
          His reply, as he scooted over in his chair and made eye contact with me from about a foot away: “Well, sir, it’s kind of like this. Imagine 5 years from now, after you have died, I am in court and the judge asks me, and you didn’t remove it because……..”?
          My reply: ” Good point. Got it”.

          One thing I have noticed the last 20 years is the anger and distrust of so many professions. People hate lawyers, until they need one. Many are late paying their bills. Everyone hates Govt workers, yet they know nothing of their duties, renumeration, or how they are paid. Everyone has been to school so they believe they know everything about teaching and teachers, when in fact they know absolutely nothing about the profession. Mechanics? Store owners? Police? And with the Internet and home diagnosis, many believe they know what their Doctor should be doing.

          When I was a float plane pilot flying loggers into camp on the BC Coast, (probably one of the most dangerous jobs around other than helicopters and long-lining), I would have long-time customers sometimes say to me, “You know, I have been flying in and out of camp for 20 years. I could do your job, it looks pretty easy”.

          My reply was always, “You know, it is easy. It’s just a machine. I’m sure you could do it hands down if you just got the ticket and someone would hire you. No problem”. There is no point in arguing with ignorance, or getting mad about it. People who know what they are doing always make their jobs look easy and doable.

          Anyway, I just wanted to speak up for Doctors and the single-payer system.


      • Ron Greiner says:

        Micheal, so you advise people to pay cash and not apply the charge to the insurance deductible and the insurance company hates that?


        • Michael Gorback says:

          Hey Ron, nice to see you again. I don’t know exactly how insurers feel about patients paying cash instead of eating their deductibles. Quite frankly i dont care if they like it or not.

          What matters to me is that the patient, by obtaining a lower price, gets no credit for that in terms of having it applied to the deductible.

      • RDE says:

        In medicine, and in any other field, there are many conscientious practitioners who have the interest of their patients at heart.

        But this does not change the fact that the American medical system is designed to produce medical extortion rather than health care.

        Medical expenses are the second highest line item after housing for the America public. And almost all the “growth” in the economy since the Obamacare scam launched is due to escalating medical costs. Even for a system somewhat similar to that in the US, citizens of Holland pay $100 for the same coverage that costs Americans $264 dollars. And the cost differences are far greater if you look at the average for all developed industrialized countries.

        If the $16,500 per year your average family pays for health insurance gives you “good” coverage, and you have enough savings to pay for the co-pay of a major operation— easily $40,000, then you may think everything is just fine. But the bloated cost of the American medical extortion system is not free. It helps starve the society of other needs like efficient public transportation or a functional education system. And is one of the reasons why parts of the country look more and more like the third world

        And it isn’t as if Americans are receiving superior health care. The World Health Organization consistently ranks the American medical system in the upper 30’s worldwide, alongside poor countries like Cuba and far behind emerging countries like Colombia.

        1- Abolish the drug monopoly patent system and with it for-profit drug sales.
        2- Develop new drugs through publicly funded research institutes.
        3- Expand medical education to provide free education for the most qualified instead of turning out permanent debt slaves.
        4-Increase the number of doctors so they work human schedules and focus upon patient care rather than meeting quotas and filling out paperwork for insurance billing and liability protection.
        5- Single payer system for all medical care and pharmaceuticals.

        Not going to happen until after the Revolution—.

        • Michael Gorback says:

          RDE we are on the same page. Why do you think I write these pieces for Wolf? It certainly isn’t for the feedback in many of the comments, some of which are so nasty that Wolf edits them out.

          The bright side of this latest disaster in US medicine is that perhaps, coinciding with rejection of the establishment as reflected by the political viability of wild deviations like Sanders and Trump, we will indeed have a revolution.

          In the meantime I will just soldier on, trying to throw a little light into the dark corners. I wish I had more time to devote to this. Most of the medical voices you hear in the media are from academicians who do not sit in the exam room trying to figure out how to get a patient the care they can’t afford.

      • c smith says:

        Unfortunately “prudent medical practice” has been defined downward by the plaintiff’s bar. Physicians order test after test to protect themselves from a crazy system of malpractice awards.

  3. Colorado Kid says:

    My last checkup by the doctor cost me $120, and that included blood tests. I live just down the road from Aspen, and prices here are high, but I was given a reasonable price because I paid cash. I pay cash for everything and don’t even have a credit card, and I often get cash discounts for everything except groceries and gas.

    Once we get the insurers out of the medical system, a box of tissues in the hospital will no longer cost $50+. If everyone carried disaster insurance with a high deductible and didn’t expect to have minor things covered, medical costs would plummet.

    In addition, I know several docs who are getting out of the biz because of the onerous insurance/Medicare/Medicaid requirements that are getting more and more impossible to meet. A typical office will have one person dedicated to filing insurance claims only.

    Hospitals and offices talk about the expensive costs of equipment, but that also would decrease if the medical community made do with not having the latest and greatest which is paid for by consumers. I have a friend who makes a very good living selling older equipment to Mexican hospitals where it continues on the job for years after being dumped by the hospitals here. Sure, sometimes advances are great and you hope the doc is using good equipment, but sometimes it’s just not necessary. I have another doctor friend who started a company advising medical billers how to maximize use of Medicare codes w/o being illegal, and he’s making a killing. The whole industry is bloated and out of control.

    • Michael Gorback says:

      To rephrase what your friend is doing: He’s showing billers how to avoid under-billing Medicare. If the doctor is entitled to $100 but is only billing $75 because his staff doesn’t understand how the codes work, he’s leaving money on the table. Advising how to collect $100 that is legally owed isn’t unethical.

      No argument from me about your final statement. At the core of the system is a patient and a doctor. A lot of money gets moved around as those two work together on the patient’s problems, and the vultures have come in to feast on it. Patients and doctors have the least effective influence in D.C. compared to insurance, hospitals, drug and equipment manufacturers, etc.

      • Me Again says:

        I beg to differ. I do my own Medicare billing so as to learn everything. IF I ask my patients such stupid questions as “if they drink, or drive, or smoke”, I can file this exam under a different code. By doing this, the difference between THE EXACT SAME EXAM and asking BS questions can mean HUNDREDS OF DOLLARS.

        It is a scam. It is LEGAL, but it is a rip off. I won’t s top since the stupid public allows this. (P.S…..I just bought a 2016 Silver loaded Corvette for $76,000 all paid for by up-coding LEGAL Medicare billing…….)

        I hope my comments make all of you sick, but as long as the stupid public believes the lies of Politicians and Insurance Reps, you can keep paying for my new cars. The Solution? Patients pay the Doctors directly and the patient gets reimbursed from the Insurance companies and ALL Doctors must post their prices.

        Patients shop around for their Doctors and their Insurance. Takes some effort, but…….Problem solved.

        • c smith says:

          Bureaucrats spending my (tax) money will NEVER spend it as efficiently as I do.

  4. NY Geezer says:

    The insurance industry has corruptly inserted itself as the controller of in the US health care industry by hiring many hundreds (thousands?) of lobbyists (bribers) to influence (bribe) lawmakers and regulators.

    The so-called health insurance that many people are buying today used to be called Catastrophic health insurance.

    Catastrophic health insurance was meant to be only a financial safety net. It was insurance just in case you have a health catastrophe. It was not intended to pay for everyday health problems. It was only intended to pay when you have very expensive health care needs. Because of this, catastrophic health plans were priced to cost much less than ordinary health care plans.

    The Catastrophic health insurance policy had a yearly deductible that was sufficiently high that for most healthy people it would usually exceed a year’s medical expenses – the year would be over before the insured spent that much money on health care.

    Because insurance companies rarely paid catastrophic medical claims the annual premium was very low. Since nobody was legally required to buy it the premium had to be cheap enough to attract at least a few buyers for a product that was very very profitable for the insurance companies.

    But today under the Unaffordable Care Act these former Catastrophic Care policies are being sold for high premiums to the American public as ordinary health insurance policies. And Americans are compelled under law to buy this crap.

    So why does the US Government pretend to be unable to understand that it is one of the causes of our high health care costs?

    • Michael Gorback says:

      Did anyone think covering all those millions of uninsured people would be free?

      Did anyone think covering very high risk individuals who previously couldn’t buy insurance at any price would be free?

      Did anyone think providing insurance to elderly people at rates below their risk level and shunting the difference to young healthy people would work?

      What’s happened is that old and/or sick people are not paying in accordance with their risk. The system depends on young healthy low risk people buying overpriced policies and those people don’t see the value.

      The result is a system that can’t support itself. Too much uncompensated risk. Insurers are losing money on the Exchange policies and withdrawing from it. For example, I was unable to find an individual PPO policy for 2016 in my county. I bought an HMO bronze plan paired with an HSA. I saved $3,000 in premiums so if I spend less than that, I win. If it comes out to more than $3,000 I’d still rather pay more out of pocket to those who actually provide me goods and services than to the insurance company.

      And thank you Mr Obama for the maternity benefits for my 56 year old wife.

      • RDE says:

        Not free, Dr. Gorback
        Just 260% less expensive like in Holland, the second most expensive health care system in the world. Or 500 to 1000% percent less expensive like poor countries that make optimum use of limited resources to provide longevity expectations similar to those of the USA.

        • Michael Gorback says:

          RDE, if you add patients to an expensive system without changing the system the cost has to go up.

          My favorite example of how Obamacare failed to address a huge problem in the system is Medicare Part D. This is a program that was introduced under w to cover medications for Medicare recipients. I call it the Uniform Gift to Pharmaceutical Manufacturers Act because part of the legislation forbids Medicare from negotiating prices.

          One reason why healthcare cost is lower in many developed countries is that these government-sponsored systems can negotiate lower drug prices. So when Mr Obama was trying to cut healthcare costs why didn’t he make it part of his program to allow Medicare to leverage it’s millions of patients to get better prices from the drug companies?

          The answer of course is lobbying and political pressure. Obama was not going to get anything accomplished without the support of insurance companies, drug manufacturers, hospitals, and equipment manufacturers.

          There was a lot of division amongst American physicians along political and philosophical lines. The AMA, which many people perceive to represent American Medicine, endorsed Obamacare. Naturally Obama use this as political propaganda.

          There are a couple of major problems with this endorsement. One is that fewer than 20% of American doctors are members of the AMA as they feel it no longer represents their interests.

          Far more important is the fact that the government has endowed the AMA with a monopoly on the coding structures that are used for billing and describing services. These are known as CPT and ICD. The AMA makes the vast majority of its money selling these code books. A little bit comes from membership fees.

          The doctors who are elected as leaders of AMA and the issues it addresses are really little more than a facade that the corporation uses to hide its real business. The elected doctors come and go but behind the scenes is an an army of people in suits who actually run the show. If the AMA had refused to endorse Obamacare you can be certain Obama would have killed that monopoly.

          If you’re ever in Chicago drop by AMA headquarters. It would make a Saudi prince envious.

        • RDE says:

          Hi Michael
          Just wanted to thank you for your detailed responses to the many comments your post elicited. And I’m sure we are on the same page on all the major issues.

        • Michael Gorback says:

          RDE: maybe. Some of the things you suggest may not be feasible. Philosophically I am very leery about single payer simply because it gives the government complete control over your medical care. They can decide what drugs you can take, what surgeries you can have, etc. I think they already control too much of our lives and they are constantly seeking more.

          Right now we in the US have a hodgepodge of insurance companies controlling our care with contradictory and inconsistent policies, but you can switch insurance companies. Switching countries, not so much. As an aside, I’d move to Canada in a heartbeat if it wasn’t so damn cold – not for the health care but because it’s a great country with great people. My parents took us to Canada several times when I was a kid, and my wife and I honeymooned in Quebec (It was June and it snowed). We’ve taken our kids there to continue the tradition. Maybe once the property bubble bursts I’ll be able to pick up something in Vancouver.

          One thing that no one seems to want to talk about is the deflationary effect it would have if we changed the system. In the US healthcare is 17% of the economy. If you cut drug prices, eliminated insurers, cut physician pay and so on it would be massively deflationary and throw a lot of people out of work.

          My prediction is that they will continue to fiddle with it until it breaks. In private industry when you screw up you get fired. In government they figure you need more staff and a bigger budget.

          Every developed country is staring down the barrel of a cannon called demographics. Health care and pension promises have been made that simply can’t be kept in the face of the wave of Boomers coming through combined with reduced birth rates.

  5. unit472 says:

    I was hospitalized in January after the drug regimen I was on left me neutropenic, i.e., with no immune system so any infection could be lethal. I laid in a bed staring at the ceiling for a day before any ‘treatment’ began. It consisted of a single shot to stimulate my immune system. It took all of 5 minutes for the RN to come in and give me the injection.

    A ‘hospitalist’ came in on the third day of my stay and I asked why I could not go home and drive to my doctors office to get my daily shot and give a blood sample. He said that I was too vulnerable to infection ( though he came in without the face mask all other nurses and staff had to wear as I was in an ‘infection control’ protocol. I pointed out that hospitals were notorious for infection as his failure to follow the hospitals own procedures indicated. He said he ‘didn’t have time to argue and that his medical degree was superior to my commonsense suggestion that my car or an ambulance could deliver me to the emergency room in minutes should I feel unwell or notice any problem.

    Here’s the issue. The hospital charged $8000 per day to lay in a bed. The shot was extra. I could have stayed at the Ritz Carlton and had my room sterilized daily for that kind of money. I told that hospitalist he was engaged in ‘asset stripping’ patients for revenue as I got stuck with a $5000 tab for the 5 day stay. To add insult to injury this hospitalist has sent me a bill for $399 for his ‘services’ though he never so much as applied a stethoscope or came within 10 feet of me during his sole visit to my room. I sent him a copy of the e-mail I sent myself the day he visited detailing his violation of the infection control protocol and asked would he rather have the $399 or have me forward this e-mail to the hospital administrator? Haven’t heard back from him.

    • Michael Gorback says:

      You need to write to the CEO of the hospital. They take these complaints seriously. There is supposed to be a utilization review process to get people out of the hospital as soon as appropriate. Hospitals also take patient complaints about behavior and breaches of protocol seriously.

      You can also contact your insurance and contest your bill AFTER you’ve seen it (more on this below). If you object to what you owe tell them you believe you were needlessly (in your opinion) kept in the hospital and that the hospitalist probably didn’t provide the level of service billed.

      Keep in mind that in medicine there’s a huge difference between billing and collecting. That guy might have billed $399 but it’s likely he’ll get much less. You can bill whatever you want but you’ll get paid the contracted rate. I can bill Medicare $1,000 for an office visit but they’ll still cut me a check for $35.

      So wait and see what the EOB (explanation of benefits ) says. There will be the billed amount, the contracted allowable amount, some numbers regarding your co-pay and deductible and so on. Then there will be a calculation of what your share of the cost is

      When my wife had her appendectomy the hospital charged $19,000, reduced to $2,000 after contractual write-offs, so I’d wait and see. However, you should let the hospital know about your experience. I would surprised if they didn’t respond.

      • IF I told you I would be arrested says:

        The EOB (Estimate of Benefits) are written so as nobody can understand them. I’ve been “in the business” for over 30 and I still can’t figure some of them out. There is no way the average patient can understand them. They are written that way on purpose. You know it.

        Added to that, you get paid different amounts from different Insurance companies, for the same exam, yet have to charge ALL of them the same amount. And GOD FORBID you offer a “cash” price that is NOT the same as what you bill the Insurance companies, unless you trust the patients to keep quiet and work with you. BUT, if they attempt to send in a copy of your lower price hoping their insurance company will still reimburse them, all hell will break out from the Insurance companies.

        Thank goodness coding for billing is so bizarre that you can charge different prices by knowing how to perform/ask additional questions (history, family history, etc) so as to legally fake it. For my line of work, I charge from “$ O” (certain patients) all the way to $259 for the EXACT SAME EXAM but am clever enough to use different billing codes by asking additional absurd useless “questions”. Sick, but legal.

  6. Yancey Ward says:

    Dr. Gorback,

    In the example you gave, where the patient paid cash rather than get billed for the deductible via insurance claim, does the cash payment count against the yearly deductible? I am guessing it doesn’t. Just one more reason to hate the health insurance structure.

    • Michael Gorback says:

      Yes, I mentioned that. “To complicate matters, if you go the cash route it doesn’t apply to your deductible.

    • CENTURION says:

      Look at is this way:

      90% of your doctors and nurses are good people and don’t want to cheat you.

      10% are crooks.

      BUT, 90% of your Politicians and Insurance Corporate leaders are crooks.

      10% are perhaps trying to be honest.

      That is the problem.

      Single Payor? Now you will 100% dishonest.

  7. Bobster1 says:

    I live in Mexico, and costs in the private system are typically 5-15% of the cost in the US. Health insurance isn’t that common because costs are low and many people qualify for one of the government health systems. You can often walk in and see a specialist without an appointment and pay $25-45 for the visit, and many specialists speak English. Most drugs can be purchased cheaply at one of the national pharmacy chains, where you can see a doctor for free or under $5, depending on which chain you use. It isn’t perfect but I’ve never heard of a bankruptcy in Mexico due to medical bills. The better private and public hospitals and clinics have up to date equipment, according to the book, “Mexico Health and Safety Travel Guide”, which rates Mexican hospitals. It’s common for a doctor to spend 45 minutes with you, something that never happened to me in the US.
    You can easily live in Mexico for the cost of a mediocre health insurance policy from the US.

    • Chip Javert says:

      Yes, and who doesn’t trust everything Mexican. Probably explains why 10% of the population born since 1970 has “migrated” to the USA.

    • CENTURION says:

      If it is sooooo good why do Millions of Mexicans steal across the border (a Felony) to get to America?

  8. D. Bruce Turton says:

    Some time ago a study was done showing the difference between what insurance costs were in Massachusetts and British Columbia – they have equivalent populations. With the plethora of insurance companies vying for all those Americans dollars there were several thousands insurance company employees to administer the systems. In B.C. there were some 450 employees administering the system for the same number of people with the Canadian health care system.
    Further studies show that the U.S.A. population pays about 15 to 17% of GDP for health care while Canadians pay about 9%. And Canada does not have the best health care in the world – we are gouged just like Americans for drugs!
    I recognize that the “free enterprise” mantra holds a lot of sway south of the 49th parallel. We have had many advocates in public life who believed the same thing was good for us too, but they were defeated in their attempts to educate us ever damned time!!! Surely, if Americans understood more about what they are paying for health care, there might be some sort of movement toward a universal system!
    But then, I do forget about who owns your mass media – the same mantra spewers who own your politicians.

    • chip Javert says:

      Health care insurance is anything but a “free enterprise” system. It is a heavily regulated, government controlled business.

      Quick example: if you live in state A and like an insurance plan offered in state B, you can’t buy it (regulation says so…). No businessman would set up a system like that.

      • Owl says:

        Yes. Some Americans love to moan on about the “military industrial complex.”

        However, the “insurance industrial complex” is a much greater threat. I try to use that expression as often as I can with colleagues hoping it will sink in and become prolific.

        Who here hasn’t received their monthly geico mailer this month. Makes me wonder if they ever pay out any claims.

    • CENTURION says:

      Make Health Insurance Illegal (or, better, make it illegal for Doctors to be paid by corporations, including Health Insurance Corporations) and make it illegal for any Government entity to get involved in health care (enforcement of contracts, ok, but OUT of the involvement of health care).

      It will be a shock to the system, but in the end it will be cheaper, better and faster and more honest.

      Those who can’t afford it? That is why we have Churches.

  9. No Straight Path says:

    Dr. Gorback,

    I always enjoy your articles. It is refreshing to see a physician that takes an interest in the cost efficiency to the patient of their practice. I have long blamed physicians for our current insurance crisis because of my perception of seeming passivity/disinterest in actively managing the financial side of their profession because it was easier (and much more profitable for many) to surrender/allow the insurance/business/middlemen skimmers to manage it. Now the doctors are being forced into large medical groups and have lost much of their professional and sometimes medical control to the skimmers (Hospital group & Insurance CEOs) who get more benefit than either the doctors or patients.

    I have long thought that ultimately the best compromise for everyone would be fully transparent pricing by doctors & hospitals with what I call a single payment processor system (government or non-profit organization) that intermediates insurance claim processing for patients as a firewall between independent doctors and the private private insurance industry. (Ideally all private insurance & hospitals would be non-profit with caps on executive compensation or stock/bond holder returns as well.) This intermediary would serve both to 1) consolidate all medical procedure data (frequency, cost, outcomes) providing a single complete data source for medical research and individual insurance company actuarial and fraud detection needs and 2) provide a single source to patients for all information of doctor’s pricing, procedural experience and outcomes when making decisions on healthcare provider selection and spending 3) provide a single point of claims contact and independent procedure approval to reduce doctors’ administrative overhead.

    This way patients have a third party arbitrator preventing insurance companies from denying/stalling valid claims or dictating practice to doctors; it could allow doctors to independently charge to the market based upon market factors (quality or competitive) and give patients the information and competitive market forces required to allow for cost effective health care,

    Now excuse my fantasy – back to the real world – I only wish what you say in your article regarding paying/negotiating a cash payment in-lieu of an insurance claim against a high deductible were possible for me. I live in Florida, so maybe Texas is different, but on multiple occasions, with different providers, I have attempted to negotiate what you describe. In all cases I have been told that since I have insurance it is illegal for them to negotiate a lower price for direct cash and that I must submit the claim and pay according to the negotiated price within my deductible. I haven’t pressed or researched to find out if it truly is illegal (perhaps it is a violation of their network contract with my insurance provider and they say it is illegal to make patient acceptance easier) so maybe I just need to find a doctor outside of my insurance’s network. In any event, until medical care, pharmaceuticals and insurance becomes more value based and less of an extortion racket, I think more and more will forgo the entire industry so as to lead a higher quality of economic life (albeit in perhaps a shorter time span) or perhaps pass more on to their children with a greater acceptance of a “when it’s time to go.. then it’s time to go” philosophy.

    • Michael Gorback says:

      No Straight Path,

      I’m not sure if it’s really the case that you can’t bypass insurance. Does your policy force you to always use your insurance? If not, aren’t you free to elect not to use it?

      Have you ever had a fender bender and chosen not to put in a car insurance claim? Did anyone go to jail?

      In what way is an insurance company harmed if you don’t ask them to pay for something?

      If you see me under insurance and I tell you I’ll just bill the insurance and not collect your co-pay that’s arguably fraud. I bill the insurer $100. They write a check for their part, $80, and you’re supposed to pay $20 but wink-wink-nudge-nudge I don’t bill you. It can be argued that my real fee was only $80 and the insurer only owed me 80% of that, or $64.

      So you can’t routinely fail to bill co-pays as a blanket policy, BUT you can make exceptions for financial hardship on a case by case basis.

      However, if you choose not to use your insurance I don’t see see a problem. You might contact the state dept of insurance or the medical society for clarification.

      If an insurer ever gives me grief for providing a lower price they can go to hell. I’ve said goodbye to Aetna and United Healthcare and I’m still in business, often seeing their customers out of network for a higher fee. The patient also pays more to see me out of network but it’s their choice and if they feel I give good value for the extra cost it’s all good.

    • I Can't tell You. says:

      You are correct. As an Optometrist (Not a “real” Doctor) I still have to abide by Insurance rules and can not offer you a discounted cash price.

      I do it anyway.

      Shop around. There are many who will charge you a cash price but what you pay doesn’t go towards you deductible.

      Why do I do it and risk getting in trouble? Every single Insurance company is over-loaded with the same paper work we are. They don’t have time. They don’t really care to investigate. They know what is going on and they really monitor the “Big Boys” or the major Hosptical networks and don’t have the time, money, staff nor will to check into little people like me. They actually LIKE IT if you pay cash since you will not meet your deductible and they say all that money.


      In the past 35 years of my “practice” only once has any Insurance company questioned me. I played “stupid” (as all Politicians and Insurance Companies do) and blamed it all on my new employee (lie) saying they are in training (lie) and that I will get to the bottom of it (lie) and get back with them (lie) with the TRUTH of the matter (lie).

      I never heard from them again.

      The entire system is corrupt. Get used to it. As long as there are Parties between YOU and the DOCTOR, there will be corruption.

  10. Curious Cat says:

    “I think there’s something very crooked about the whole Pharmacy Benefit Management business.”

    The entities who are getting the kickbacks from the PBMs are the employer organizations that hire them. The relationships between the PBMs, the employers and the pharmaceutical companies is positively Byzantine.

    For anyone one with the courage to explore the topic I recommend this study by the California Healthcare Foundation published in January 2003. It’s 13 years old, but I am sure things have gotten more convoluted if anything.


    Until the early 1980s health insurers did not typically cover drugs, or if they did they covered them as an “extended benefit”. Then HMOs came along and offered drug coverage as a carrot to lure membership into accepting restrictions on who patients could see for care. Other types of health insurance were then forced to offer drug coverage to compete.

    In the early 80s, pharmaceutical costs made up about 6% of all Medical spending. By the late 90s that had grown to about 35%. I saw a recent figure that drug costs now constitute 12% of ALL CONSUMER spending. HMOs opened the door because pharmaceutical companies saw guaranteed revenue streams and realized HMOs would end up paying whatever the Pharms charged.

    I used to teach a course in health economics. I’d ask the students to discuss what would happen if someone invented a drug for immortality but cost $10 million a dose. I never dreamed of how quickly that might happen.

    • Michael Gorback says:

      PBMs have been flying under the public radar. Their role is hard to understand but as middlemen in the system it seems to me like they should be looked at for RICO violations. There are good articles to found on this on the web but the convolutions can be hard to follow.

  11. walter map says:

    I don’t know where it came from, but I suddenly have this urgent need to go home and hide.

    • Michael Gorback says:

      Walter, have some perspective. You have a reasonable chance of not requiring expensive health care. OTOH, chances of suffering the consequences of central bankers and the next POTUS are 100%.

  12. I Can't tell You. says:

    I am an Optometrist. There are 16 different billing codes for an “eye exam” and that allows me to have 16 different (BS) prices. I also take Vision Plans which are a total rip off.

    Luckily nobody dies from Contact Lenses or Eyeglasses, thus I don’t have as much pressure as the real Doctors. BUT, since I know how corrupt insurance & Vision Plans are, I make up my prices for the benefit of the patient and me. You have a goofy Vision Plan? I’ll take them for every dime I can legally do. Have Medicare? I’ll bill the legal codes and max out my payments.

    Basically, I have the “Usual and Customary” fee, but, as I mentioned, I have 16+ of them. I would love to have one price and only one price for an “Eye Exam”, but all this BS won’t let me. So, I have learned the game and make a lot of money…..not from my “private pay” patients who I help, but the thieving corrupt Insurance/Vision Plan thieves.

  13. Tom says:

    Dr. Gorback,

    Thanks for the great article. I plan on asking about a cash option with my local doctors since I am one of those with a high deductible plan.

    I would add two things: first, high deductible insurance is basically asset protection from non-nursing home expenses. Second, I know of a large local hospital that has a financial assistance program that covers 100% of uninsured expenses for those making below 200% of the Federal Poverty Level. Reduced levels of debt forgiveness are given for higher levels of income on a graduated basis. I suspect that other hospitals have similar policies for those that know to ASK for them.

    The problem is that the seriously ill have little ability to fight a large bill during their recuperation. That task should be taken up by an able family member, if there is one.

  14. nick kelly says:

    I think big pharma and the providers are in for a jolt- after the Valeant bit there will be hearings going on during the election campaign (after candidates are chosen)
    They look like a sell

  15. jim wilson says:

    Yikes. Glad I do not have to put up with all the “shopping” and “comparing”. It is easy, hearing these stories to understand how Canada spends less per person on health care, and gets better results, primarily by eliminating insurance companies. From my father’s heart issues, to my mother’s broken arm, to checkups and other surgeries our costs have been minor (extra for upgrading to a semi private room). Sure we pay more in taxes, but am I ever glad the decision process is a piece of cake. Doctor says – “you need to…”. Me “ok”. The savings in peace of mind are outstanding.

    We do see it in dentistry though. Not covered by the government we are at the mercy of private … and insanely expensive and over the top charges … by dentists and health insurers. My last crown I had done in Asia and saved enough to almost pay my flight over there (and yes, great care) as I was going on vacation anyway. You see it in the fancy offices, 4 month recalls for checkups,… I hate it.

    • Petunia says:

      Thanks for reinforcing my opinion that America is long overdue for a national health insurance program. It’s too bad Obama backed down from implementing it.

      • Paulo says:

        I did reply up above so I won’t restate. However, our biggest concern is ensuring our supplemental travel policies will cover the gouging if we get sick down in the US. Canadians have to read the fine print. We pay about $150 for a 1 week policy of extra coverage when we go down to see my sister in WA State. There are weekly horror stories in our media of folks owing 100,000 + for getting sick “down there”.

        My wife and I are retired. My wife has been a type 1 diabetic for 45 years. She is in excellent health at age 56. We pay approx. $300/month for all medical, dental, and 80% drug coverage, as well as a yearly eye exam and money towards glasses. (For both of us) As I said, I have had cancer surgery, appendex removal, two knee operations, broken legs, fingers, and numerous wounds needing stitches, (active lifestyle, here), and have yet to receive a bill. We do pay more for fuel and booze up here to cover it, and higher taxes, but hey….I would be living in my car if I had to pay US medical bills.

        • Michael Gorback says:

          Paulo all you need to do is what Americans do: don’t pay the bills. What do you think will happen? Are they going to come up to Canada and take your house? Have you extradited?

        • nick kelly says:

          Re: don’t pay the bill. I see a guy was just arrested for not returning a video rented over 10 years ago. I think not paying a US bill is an idea- but not if you plan on entering US again.
          Many US non-payers will not be worth pursuing- but it is easier to DENY something than to recover it.
          Not that long ago a guy went to get on plane to Vegas the same as he and wife had done for years. No this time- wife had a shop lifting conviction from 20+ years ago.
          All bureaucrats are a bit weird but the US is in a class of its own

        • Michael Gorback says:


          The video arrest was because when the customer failed to return the video the store owner filed a criminal complaint for theft. And it wasn’t even a good movie.

          Nobody cares about medical bills. If it’s on your credit report that you owe the hospital $10,000 it won’t make a bit of difference. The hospital might send you to collections but nothing is going to happen in terms of criminal prosecution.

      • Chip Javert says:


        Ah, yes; the government does so well at managing health care. Take, for example, the VA system, or Medicare, or (for that matter) Obamacare. But I’m sure they’ll do better once they control everyone’s medical access.

    • Michael Gorback says:

      Before Americans convert to a Canadian system they should go visit the government Web sites that report on wait times. No American would tolerate what Canadians put up with.

      As I understand it these sites were instituted because of complaints of long waiting periods for care.

      Take a look at wait time statistics published by each province and see if you would want to wait that long.

      According to the Wait Time Alliance (waittimealliance.ca), you should be able to get a CT scan or MRI within 60 days. Really? Is that what happens in the US? I can get an MRI done for a patient within 24 hours at several facilities within walking distance from my iffice.

      Their target to have heart bypass surgery is within 6 weeks, although the Canadian government benchmark is 6 MONTHS. I don’t want to wait 6 weeks, let alone 6 months.

      It can weeks or months just to get ear tubes inserted for a child’s chronic ear infection.

      If you Google Canadian medical wait times you can see this is a national crisis. According to a recent report at https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2015-report,

      “Specialist physicians surveyed report a median waiting time of 18.3 weeks between referral from a general practitioner and receipt of treatment—slightly longer than the 18.2 week wait reported in 2014. This year’s wait time is 97% longer than in 1993 when it was just 9.3 weeks.” [Anyone consider this progress?]

      “Canadians could expect to wait 4.0 weeks for a computed tomography (CT) scan, 10.4 weeks for a magnetic resonance imaging (MRI) scan, and 4.0 weeks for an ultrasound.”

      “The results of this year’s survey indicate that despite provincial strategies to reduce wait times and high levels of health expenditure, it is clear that patients in Canada continue to wait too long to receive medically necessary treatment.”

      Speed, quality, price. Pick any two.

      Is there a magic compromise between “live and be destitute” and “suffer complications or die waiting to see the doctor?” I don’t think so. Every society has to decide where it will sit along the spectrum.

      • Petunia says:

        The lack of wait time argument is a fraud in America. I will give you some examples. Under worker’s comp I had to wait 9 months for an approval to have an MRI. In NYC the wait time for a doctor’s appt is at minimum 30 days, and that’s with begging. Metlife has made my son wait at least 30 days to get emergency dental surgery, while he was experiencing pain. Getting approval to extract his wisdom teeth only took 3 weeks. The reason people go to the emergency room is because health care is not that available to them. We need a single payer system because the current one is not working even for people with “good insurance”.

      • Paulo says:

        For WCB the MRI and surgery is basically next day so the worker can get back to work. If you want an immediate MRI you can go to a private facility. If our system is so bad, why are our health outcomes better at 2/3 the price per GDP/per capita?

        • Michael Gorback says:


          There are several possible responses to your question.

          One would be to suggest you ask Belinda Stronach, Robert Bourassa, or Danny Williams. IIRC, Ms Stronach is a liberal who opposes a two-tiered system with a private sector.

          Secondly, I did not claim that the United States healthcare system is superior to that of Canada. I suggested that Canada may not be the system that we want to imitate.

          Most importantly we need to look at the way that international comparisons are made. Among the OECD countries Canada is one of the worst in terms of infant mortality rates out ranking only the United States. Would you agree that these two countries are the worst places to have a baby?

          I would not. One of the dangers of comparing health systems internationally is that different countries use different statistical criteria. There are variations in what constitutes a live birth, in terms of gestational age and birth weight. Some countries don’t consider a birth “live” unless the baby lives 24 hrs. In the US, if the baby is born with with a heartbeat and dies 20 minutes later it’s a perinatal death.

          Paradoxically the ability to successfully deliver more preterm babies and babies with extremely low birth weight will add to the mortality statistics. A fetus that may have been aborted will instead be delivered alive. These babies have a very high mortality rate and the more successful you are at bringing these fetuses out alive the worst your mortality rates will be.

          Therefore Canada’s abysmal performance in terms of infant mortality might simply be due to classification differences and/or being more technologically capable of delivering endangered immature fetuses.

          Is Canadian health care going in a good direction? Whereas in the 90s Canada ranked number 5 out of the 17 OECD countries in terms of overall health care they now rank number 10 with a grade of B.

          Once again, I would caution you about international comparisons but if you want to use these statistics one must conclude that Canada is falling behind and Americans should be careful about following the Canadian example.

          This is conclusion that logically follows the analytical framework you chose.

      • Jim says:

        At least with a system such as Canada’s, it’s clear that the wait times are related to the politically-determined BUDGET allocated for health care. Spend more of the national budget on health care, and the wait times, access, etc, would improve.

        Compare that to the US system, where a medical emergency, or a chronic health condition, can easily result in personal or family financial ruin. Poor people – a huge chunk of the US population – have little guarantee of quick or proper access to services, and even less to the necessary followup. The health care non-system is incredibly opaque, as well illustrated in your article. Clearly, vast sums are being extracted by entities that provide no health care benefit whatsoever. We spend far more per capita, for worse overall health outcomes. We could have all three (speed, quality, price) with a sane health care system that prioritized people over profit, backed up by a budget directed to keeping humans healthy rather than blowing them into pink mist.

      • KFritz says:

        Canada seems like a good ‘jumping off point’ for comparisons to other health care systems–a primarily Anglophone (seemingly) strong First World economy, next door with an analogous culture and ‘Weltanschauung.’

        For better or worse, the default metric to assess a nation’s medical performance is life expectancy. Canada has higher life expectancy than the US, in spite of usually longer wait times for tests and procedures, and higher infant mortality.

        This doesn’t imply that the US ought to use Canada’s setup as a template for change, but it’s worth a ‘look see.’

        • RDE says:

          ” the default metric to assess a nation’s medical performance is life expectancy.”

          Life expectancy in Cuba 79.2 years.
          Life expectancy in the USA– 78.8 years.

        • Michael Gorback says:

          At the risk of repeating myself remember that there are significant problems comparing healthcare systems among various countries.

          Personally I think one of the reasons we have bad outcomes is demographics – Americans lead such incredibly unhealthy lifestyles. I see patients who are so obese that I don’t understand how they can function. Then they come in complaining about held their knees hurt. When I mention that losing about half of their body weight might be beneficial to their knees they claim that they can’t exercise because of knee pain. I’m sure that you feel like I do that this is just plain old BS . I have a cartoon in my office from a comic strip called Hagar the Horrible. In it the doctor tells Hagar that he’s overweight, he has bad breath, he has dandruff, he has bad blood pressure etc etc etc . In the final panel Hagar says is there a pill for that? This ties in with my response to Tim about the impact of public health initiatives. Sadly I think other countries are going to catch up with America. For example Italy has great health statistics but due to the increasing incorporation of unhealthy foods into the so-called Mediterranean diet they are now having increasing problems with obesity and diabetes. One of the more repellent things I’ve seen in Italy was a McDonald’s in the city of Venice. That’s blasphemy.

          There is no healthcare system in the world that can force a person to eat properly, exercise, and be moderate in consumption of alcohol. One of the more laughable concepts in American health care is pay-for-performance. That’s where doctors get paid for having better outcomes. The problem is that the doctor is not able to go to your house and pull the cupcake out of your mouth nor can he or she stand over you and make sure that you use your insulin. You can’t make chicken salad out of chickenshit.

        • Wolf Richter says:

          Some food for thought:

          The CIA’s World Fact Book puts 2015 life expectancy at birth for the US in a lowly 43rd place (79.68 years) and Canada’s in a still so-so 18th place (81.76 years).


          Some of this in the US has to do with how many Americans die as a result of violence, traffic accidents, suicide, and other causes at a relatively young age — causes that are essentially unrelated to medical care (though not necessarily unrelated to mental healthcare).

          If we manage to survive long enough and get older, our life expectancy at age 65 rises to be somewhere near where the top other countries are.

        • Michael Gorback says:

          Before you give credit to Canadian medicine for better longevity, please consider that it has been that way as far back as 1960.

          Maybe it’s something in the water.

          In 1960, Australia lagged Canada, but now surpasses it. Maybe we should be looking at Australia.

        • KFritz says:

          According to the this graph from “National Vital Statistics,” death by violence and accident isn’t anomalous after age 45, when the gap between the US and other comparable nations does seem to narrow.


          This graph seems to indicate that death by violence and accident isn’t very significant–statistically. It’s certainly ‘significant’ to ‘participants’ and their families.


          Bearing in mind that correlation isn’t causation, the gap seems to narrow even more at age 65, after which Americans are covered by our version of socialized medicine. This website is the one I skimmed.


          Saying that Canada’s relative position in world rankings has slipped is partially relevant–at best. In spite of any troubles, life expectancy there has increased during the last 25 years, as it has in the States. And it’s done with approximately 60% of our expenditures. And anyone scandalized by 5 month waits for surgery (with the assumption of palliative care during the interim) will have their eyeballs scorched by the underside of US medical care.

      • RDE says:

        Statistics are very nice to quote, but my personal experience with Canadian medical system wait times was exactly the opposite.

        As an American working in Vancouver, I was called into the company financial office soon after starting work. “Have you received your Care Card yet?” “But I’m a Yank.” “Here, fill out this (one page) application form. You are in a civilized country now. We don’t permit people to go without medical care.”

        I used the system three times for non-critical cancer exams that would cost $ 2500 to $5000 in the US. Wait time— 24 hrs.

        Speaking of statistics, it would be interesting to compare the indebtedness of recent medical school graduates in Canada and the US—-. Debt slavery is still slavery. And speaking of statistics, how much does the average American doctor in private practice pay annually for liability insurance?

        • Michael Gorback says:

          RDE, with all due respect, you can’t cite statistics to support your arguments and then toss them aside when they don’t fit your narrative. If you believe the statistics you’re stuck with them , good or bad. You can’t turn them off and switch to stories.

          As they like to say in the statistical world, the plural of “anecdote” is not “data”.

      • jim wilson says:

        Unfortunately you miss the key differentiating factor – urgency. You can get an MRI in an hour if it is critical. The same for most if not all treatments. What the system does do is makes sure the MRI machines are constantly in use, which means we have fewer of them (less cost) but utilize them more efficiently.
        Sure sometimes the wait times for non critical issues can be long, but I never worry about not being able to afford them. – and that alone probably helps my overall health. Most Canadians would NEVER trade our system for the US clusterfuck of system.

        • Michael Gorback says:

          One more time for the mouth breathers: I’m not saying the US has a better system, just that when we look for a replacement Canada might not be the model to follow.

          Using the statistics that Canadians like to cite to demonstrate the superiority of their system, it looks like it’s backsliding. Wait times have doubled since the 90s and international rank has fallen significantly. Those international comparison stats you like to use indicate a system in decline.

          I think there’s an element of satisfaction due to diminished expectations. To me it’s unacceptable to have a child suffer months with ear infections before getting a 5 minute operation but in Canada it’s not only acceptable, it’s standard.

          Despite the cheerleading, it’s impossible to ignore the persistent news stories about wait times and the need for better funding.

      • nick kelly says:

        2 years ago my 55 year old lady friend felt breathless at 2 AM- ambulance arrives within 10 minutes takes her to Nanaimo General Hospital ( on Vancouver Island) She spends nite there.
        The next day she has tests. The next day an ambulance takes her to Royal Jubilee in Victoria, 60 miles away.
        The next day she has stent put in heart
        The next day (or maybe two) she is discharged and I pick her up.
        Next week she is back at work.

        Next item: I burnt my arm and ignored it until it bubbled up and I went to Emergency at Nanaimo Gen. I gather from many sources I should have gone earlier. The doc kind of freaked and for the first time in my life I was on a intravenous drip (antibiotic) ten minutes later-
        The doc had some words that were supposed to be reassuring- don’t worry- you’ll be seen by a top man!
        Anyway sure enough I was seen by a specialist within another 15-20
        who managed to calm down both the doc and me.
        After the crisis had passed I had to go to day care every day for a few days while a nurse picked the dead skin off.

        Last item; years ago during a financial crisis- I had difficulty breathing and lady drives me to Emergency.
        I was having an anxiety attack!- and they are no fun.
        So the newly qualified doc (who became my regular) gave me some ativan but referred me to a psychologist who over a few visits gave me relaxation training- basically in the mind-body connection. Breathing, listening to tapes, that kind of stuff. Worked. All covered.

        So I can’t bitch too much.

        • Michael Gorback says:

          Nick, when you saw the psychologist did you pay out of pocket?

          I went online and according to the CPA,

          “In Canada, the services provided by a psychologist are covered by provincial health insurance only if the psychologist is employed by, for examples, a hospital, correctional facility, community clinic, social agency or school.

          The services provided by a psychologist in private practice are not covered by provincial health insurance plans and the psychologist bills the patient directly. Many people have extended health benefits through their employers that cover some amount of psychological service annually. The services of a psychiatrist, whether they work in a hospital, clinic or in a private office, are covered by provincial health insurance plans. As is the case for psychologists employed in hospitals or schools, wait lists to see a psychiatrist can be long.”

          There’s that waiting thingie again.

        • nick kelly says:

          No it was covered- the psychologist (or whatever he was) but this was decades ago. Not too long ago your doctor could prescribe up to 6 massages per year! Happy ending probably not but still tempting. That’s gone.
          A whole bunch of non-MD stuff is still covered some of it probably quackery.
          Oh that jogs my mind- I believe chiropractic is up to a point


    well doc, i sure would like to buy you a drink some early evening and discuss equipment amortization and prices for ct scans, mri scans.

    in this sense, i am a manufacturer and acquire some sophisticated and expensive equipment. sometimes i pay cash. sometimes i have financed them. financing them[zero interest rate from fuji bank], the payment term is generally 5 years. a release of lien and the equipment is mine, free and clear.

    now, let us discuss the ct scanner, the mri scanner. i assume that most are financed[ge capital, et alia]. in the first 5 financing years, i can understand a high price for the hourly utilization of the scanner, but after the scanner owner has completed the payments, why don’t the hourly prices fall?

    • Michael Gorback says:

      Albert, Perhaps I’m not following your logic but are you saying that if I own an 18 wheeler I should drop my shipping rates after the truck has been paid for?

      How about recouping my investment in the truck? How about charging what the market will bear?

      Are you discounting your services when you pay off your notes or are you charging what you can get?

      Why should you or I lower our prices simply because our overhead went down? Who does business like that?

      What SHOULD happen is that prices should should be transparent and we should compete on that. Then someone who has no debt payments can charge a lower price and pull business from the competition.

      In medicine it’s not transparent at all. Some of that is intentional, some is a result of how byzantine the system system has become.

      • ALBERT CHAMPION says:


        the computer/chip industries.


        • Michael Gorback says:

          But not you Albert? Why don’t you practice what you preach?

        • nick kelly says:

          The computer chip business is a poor example- it may be almost unique. There are very few manufacturers in it with Intel being many times bigger than the rest combined, but all are multi- billion dollar outfits. Memory chip prices are the poster child for wild swings in price- but no hamburger chain could survive them, nor could most other businesses.

          Once the chip is designed the cost per unit can drop to pennies, if it’s a big seller. It resembles big parma- it’s not a service sector business. It’s the closest thing we have to fully automated manufacturing – so it shouldn’t be used as a example for MRI scans, where BTW, the cost of the humans per scan far exceeds the cost of the machine per scan. It doesn’t interpret its own work.

  17. Thanks for a great article, Michael. I practiced ObGyn for many years, left and opened a women’s health practice and eventually went to all cash. My patients know their costs up front, can decide if I provide value, and their out of pocket costs were far less than if they had used their insurance. And a big part of the value, as you stated above, is advocating for patients and helping them navigate the system, take advantage of cost savings I pass along to them on testing or supplies, and using their resources wisely. That’s impossible when cost is not transparent.
    I choose to pay cash for my own healthcare. I do not want the insurance in the middle, do not want them knowing my personal business. At a recent consult with a specialist, however, it would have been comical were it not such a sad commentary that the staff had no idea of the cash price when I asked ahead of time, and when I went to pay at the time of the visit, they had no idea how to do that. The whole system with insurance in the middle is a disaster, and the people hurt most of all? All of us who ever need health care at some point.

    • Michael Gorback says:

      Bobbi, thanks for your kind words.

      It feels good to be a doctor again doesn’t it? I wish I could survive on direct pay patients but there aren’t enough here for me to do that. It’s a tiny fraction of of my business.

      I would be afraid of having no insurance. I can financially survive a knee replacement but not a bad MVA and 3 months in ICU and rehab. That’s what my bronze HMO is for.

  18. TArthur says:

    Dr. Gorback,

    I have been in health care for 36 years. I have witnessed the slow but steady evolution of care provision and reimbursements. I have always felt that true health care reform would only come about if there is a direct link from the cost/price to the patient.

    My experience with insurance companies and 3rd party payors is that “they” aren’t concerned with the cost/price, “they” are all about the discount off full list, i.e the allowable.

    Perhaps it is time for insurance to become the responsibilty of the insured. Pay for / purchase the service up front, (like your cash option) then submit your claim to your insurance company. I’m sure the general public would love to get involved in the subtle intricacies of claim submission, the ubiquitous “medical review process” and of course waiting to collect the full amount previously paid. I can only begin to imagine the screaming.

    If this scheme was implemented, I am confident that rapid, sweeping reform would be priority one.

    • Michael Gorback says:

      TArthur, bless your heart. Thats how it used to work. You saw the doctor and paid your bill, then sent in your claim to the insurance company. Back then, I’m told, patients paid most of the bill. Managed care has disconnected the consumer from the cost.

      I have spoken with several insurance executives and suggested that instead of deductibles and co-pays and drug tiers, just have the patient pay a fixed percentage of everything. Then you’d see some semblance of a market with price competition as patients became more aware of pr8c8ng.

      In a sense the current scenario, although painful, might be a good thing if it wakes up the public to WTF is going on.

      • David says:

        I have heard that there are faith-based health insurance companies out there that operate in just this way and are allowed under the ACA. You pay your medical bill then submit it to the insurance company for reimbursement. The premiums, naturally, are significantly less. One that comes to mind is through Christian Ministries but there are others, also. Has anyone had experience with these?

  19. Michael Gorback says:

    Please explain how i am a slave to the pharmaceutical industry. I have no idea how they could posdibly enslave me. It seems like they’re always trying to curry favor with me to prescribe their products.

    Then explain the how being a slave to pharmaceutical companies pushes me to do surgery.

  20. Michael Francis says:

    In Australia, Medical Tourism is growing at a rapid rate. Australians fly to Thailand or Malaysia, have their operation (low cost when compared to Australian standards) and recover by the pool drinking piña coladas. The surgery offered is generally elective or ‘non urgent but necessary’ but very expensive if done in Australia.

    Your ‘sea-sun and surgical’ Asian holiday costs are packaged in the one deal, the surgery is cheap, and is of growing concern with our Medical authorities.

    Are such packages offered in the U.S. Or Canada. Interested to know.

    • Wolf Richter says:

      Yes. And they’re getting more popular. Some insurance companies in Southern California offer a lower premium if you get certain things done in Mexico. India and Thailand are big too. But for us, the cheapest and easiest is Mexico. Just a short drive away.

      • VegasBob says:

        Nowadays I live in Green Valley, AZ, about 45-50 miles from the Mexican border. It sure beats dealing with the US medical system.

    • Petunia says:

      In Florida the Cuban immigrants actually go back to vacation in Cuba when they need major surgery. If they have surgery in Florida they can be sued for their assets, usually a house and bank account. If they spend a certain number of months in Cuba, it is free. They seem to prefer and miss the medical care they received there. I learned this from watching Spanish TV over the years.

  21. VegasBob says:

    My 85-year old uncle solved the problem of insurance companies telling doctors what to do by signing up with a concierge physician some years ago. He pays one annual fee which covers ALL routine office visits.

    He still has to see specialists from time to time and he does have insurance to cover that, but as a rule he doesn’t have to fight with Medicare or his other insurer over his treatments or the cost.

  22. John Doyle says:

    Writing from Australia, we have a universal medicare system, but you can also insure privately, which many do. That way you can choose your doctor for example and not just use the one on duty at the time. I have been in hospital many times and have never had to pay for treatment. I have had both hips replaced, a decade apart. I had the same surgeon but the two hospital stays differed by a week shorter the second time. I have also had spinal laminectomies and they worked perfectly. I live in Sydney so care here is assured, not sure about remote locations, but it’s not a major issue like we hear in this blog.
    The Federal government puts up the funds and as it is monetary sovereign, the funds are taken from thin air. No FICA or such is necessary, although we do have a 1/2% medicare levy. Even that is not required. The US only lacks the political will to allow it to be the same.
    That is what must change!

    • Michael Gorback says:

      Very few votes speak as loudly as those done with the wallet.

      The fact that many people will pay extra to go outside of the system speaks volumes about the quality of the system. That applies to Oz, Britain, Italy, and other dual systems as well.

  23. Done it in Russia paid cash says:

    Done it in Russia paid cash.
    Latest equipment, nice stuff at facilities, fast service.
    Brain scan and the second procedure blood vessel scan MRI:
    Walked in without appointment, walked out in 1 hour with doctors conclusion ~ $65 cash
    Dental clinic what they call the high level service.
    the next notch in service 50% less
    Cleaning plus 4 cavities ~ $102 cash,
    asked about implant price. The most expensive with zirconium (or what ever they call it) crowns about $1500 Again it was the expensive clinic.
    Of course the $$ is high now but even before the today %100 decline of the ruble it is still little better than in US
    Looks like they are not telling us the whole truth here.

    • RDE says:

      But Russia is the Evil Empire where the head Oligarch Putin eats babies for breakfast and little old ladies starve in the street. I know because President Obama and Hellary Clinton told me so.

      • PaidWithDebt says:

        yeah and listen for them little longer and you will lose you spot under the next bridge.

  24. Merlin says:

    Invaluable article and comments section. I have posted this to my FB, and have made it required reading for my two kids pursuing healthcare careers.

    • Michael Gorback says:

      Thank you Merlin. FWIW, I told my kids I would support any career endeavor besides medical school. You come out a debt slave and will most likely be a cog in a corporate machine.

      The latter may not be a big deal for Millennials. One of my colleagues is an ophtho, ophtlalama . . . . eye doctor. His son is finishing med school. They have discussed the possibility of joining his practice after his residency training. His son told him, “Dad, you work too hard”. But not too hard to put the kid through all that school I guess. How sharper than a serpent’s tooth, eh?

      Many of the new graduates are not interested in running their own practice. They want comfort and security – set hours, vacation time, steady income, no business risks, etc.

      Dare I say they want a “safe space”?

      • Paulo says:


        I told my kids they could be anything they wanted but I would never pay for flight training. :-)

        One has his own electrical business and the other is a District music teacher.

        My son’s girlfriend is in 4th year nursing here in BC. She ran a vet clinic for her dad and he discouraged her becoming a vet. Deadbeat pet owners don’t pay.

        Is everyone disillusioned with their careers these days?

        So, in the cash version of medicine, just what will you do when a poor aquaintance comes in and asks for help? Will you turn him/her away? Will you let them die? Or, will will you basically drop them off at a medicaid facility? The brave new cash-only billing world seems to cater to just winners. Some of us believe healthcare should be available to all, at least a ‘realistic’ version of it. It should/could/can be universal and affordable. The only thing lacking is political will.

        If you can drone folks in Yemen and spend Trillions overthrowing countries, you can look after someone poor in Kentucky or West Virginia, as far as I’m concerned.

        By the way, Belinda Stronach is no one to quote in Canada. Try Tommy Douglas. :-) Stronach is just another billionaire’s kid. I doubt she would ever stand in line for anything, much less health care. She switches political parties when she perceives an advantage for doing so.


        • Michael Gorback says:

          Paulo, the examples I cited were Canadian politicians who went to the US for health care. Why didn’t they eat their own cooking and wait their turn?

          I focused on Stronach because she opposes a dual system of public and private, but apparently not for herself. I guess that’s just for the “little people”.

  25. James R Chaillet, Jr., MD says:

    Dr Gorback, a great article. As an aging family physician (working for hospital system) I see there is still hope that medicine can be made personal again and more affordable. A suggestion, which you may have already considered: promote your cash practice to primary care physicians who have already opted for a cash practice or a direct payment model where they avoid dealing with insurance companies and strive to offer more personal care.

    • Michael Gorback says:

      I’ve tried that. The result was a trickle.

      But what about when I contact an insurance company and tell them I can provide the same service for 1/3 the price? They don’t even respond most of the time.

      Why aren’t they interested in saving money? There has to be an agenda somewhere if they are not trying to steer patients away from a procedure in the hospital to an office setting.

      • nick kelly says:

        Just for amusement ( I guess ) here is true item- not an opinion.
        You theoretically can’t pay extra to jump to the head of the line in the regular Canadian system. But in at least one Ontario hospital or clinic you can pay about $ 300 and go in within a day or two.
        There is only one catch: you have to be a cat or dog.
        Paying to have either scanned doesn’t violate the Canada Health Act
        It is the same machine by the way and I assume the same operators, although not, I guess not the same interpreter, who would be a vet.

        • nick kelly says:

          Sorry for typo in last sentence and I forgot to add that this was for a CAT scan

        • Michael Gorback says:

          Nick some things are universal. I tell my patients the most efficient care they can get is if they get on all fours and bark.

          Then they will be seen right away, have blood tests and xrays and leave with medication.

          The difference is cash vs insurance.

  26. TheDona says:

    Dear Dr. Gorback, Thank you for speaking out on this issue! Hopefully there is momentum within the private medical practice arena to move this agenda forward. My Step-Mother’s Doctor recently became a concierge service.

    Here is some positive feedback on Doctor transparent pricing from my experience: Daughter had keloid under eyebrow…thought we should see plastic surgeon because; well, young pretty girl with keloid in sensitive, obvious area….we should go for the best. Researched and found Doctor (who lived in her city) who posted all of his prices from full face lift to keloid removal. He priced from $75 to $450 price range depending on area, size, etc. I thought $450 as worst case scenario is fine with me as who wants a scarred, ugly eye area. She said he was super friendly, caring, and took his time with her. After he told her about after care and provided salve; he told her he could not in good conscience charge an uninsured college student for such a simple procedure. So he no billed. I am still shocked but grateful. We floated on that act of kindness for a couple of months.

  27. Chicken says:

    So Americans are paying extra for “Mother May I” service, this confirms my long-held suspicion.

    I also have a suspicion pharmacists often attempt to interfere with physicians prescription decisions.

    • TheDona says:

      Depends on the pharmacy. You should shop that as well. CVS asthma rescue inhaler on script was $165ish. Went to Walgreens and it was $65ish. Why??? Bought on Canadian pharmacy after that and only $20 bucks. My daughter is now getting it free at her State College along with free medical consultations. There used to be a cheap OTC rescue inhaler called Primatene Mist which worked great. It was a life saver to my Sister when she was a child 40 years ago but no longer allowed on the market. Big Pharma sure squashed that a few years ago. Why would they want $10 dollar OTC with no script that solves the problem when they can charge $165+.

      Connect the dots.

      • Michael Gorback says:

        I recommend goodrx.com. They provide local price information and discount coupons.

        Don’t get me started on chain pharmacies. Fortunately I am blessed to have near my office what may be the only independent pharmacy left in the US.

        I am going to put in a shameless plug for Professional Pharmacy in Webster, TX. Owned and run by pharmacists who answer to no corporate master. I send all my patients there and they love it.

        They don’t sell cosmetics, books, cell phone chargers, or Halloween costumes, nor do they print photos. Just medical stuff. It’s like Ye Olde Apothecary Shoppe.

  28. Tim says:

    E. Richard Brown: Rockefeller Medicine Men.

    The principle gains in health care came before the era of scientific medicine.

    Nutrition and prevention. Clean water and sanitation.

    Scientific medicine has come up with important lifesaving treatments. But a major problem is the public is largely ignorant about medical topics, and so don’t know when they are being treated properly, and when they are being ripped off.

    • Michael Gorback says:

      Tim, that’s an excellent observation and a sentiment very near and dear to my heart. Much of the improvement in health and longevity has come from public health measures.

      I wouldn’t go so far as to say the gains were made prior to scientific medicine and some of the gains were not made because of medical practices or ideas.

      I disagree about the timing. A lot depends on where you peg the advent of scientific medicine.

      I would say scientific medicine begin somewhere around the early 19th century. That’s when great strides were made in synthesizing drugs, the advent of anesthesia, understanding infectious disease, etc. Koch showed that bacteria caused infections. Lister built on that knowledge to introduce antisepsis into the practice of surgery and Pasteur developed pasteurization. Morton introduced ether in 1846, which revolutionized surgery. More soldiers died in our Civil War from dysentery than weapons. At the turn of the 20th century the main causes of death were infectious diseases like gastroenteritis, TB, pneumonia and flu.

      A lot of these things were improved by public health measures. The Pure Food and Drug Act was passed in 1906. There were also movements towards cleaner water, cleaner air, sewers, better living conditions and so on.

      I think some progress was simply the unexpected result of technological change. For example during the horse and buggy era typical city streets were simply compacted horse manure and urine. Imagine a series of dry dusty days where all of that stuff was being kicked up into the air. When automobiles came along the streets literally became a lot cleaner and healthier.

      So it really wasn’t magic bullets like antibiotics that decreased deaths from gastroenteritis, pneumonia TB and so on. It was more public health measures. Later on we had some public health technological advances such as vaccines. We didn’t wipe out smallpox and polio with antibiotics or dramatic surgery, we addressed them by having vaccinations.

      An ounce of prevention really is worth a pound of cure. Thanks for a great observation.

      • Tim says:

        Lister, 1870’s
        Pasteur, 1860-64,
        Koch 1870’s-80’s

        The medical applications of the science came after the discoveries. Sometimes decades later. Scientific medicine in Brown’s book looks like it starts in the early 20th century. Large lag between medical science, and scientific medicine.

        • Michael Gorback says:

          I’m not sure what point you’re trying to make. The findings by Koch, Pasteur, and Lister were all incorporated into practice during the 19th century. These doctors performed experiments and based on the results applied them practically. Isn’t that science?

          I don’t see how you’re differentiating between “medical science” and “scientific medicine”. It sounds arbitrary and hair-splitting. I have never heard of the book you reference so I have no idea what the rationale or formal definition is that Brown uses but he doesn’t own the medical lexicon.

        • Tim says:

          One of the points is that the medical science discoveries of Pasteur and Koch resulted in pubic health applications (clean water, sanitation and refrigeration) many decades before there were any effective, relatively safe antibiotics. The applications to sterilization of operating room equipment came of course relatively rapidly, but the types of operations were much more limited than today. These all occurred late in the 19th century, not early. Bacterial infections were still a death sentence into the 20th century, as you point out. Comprehension of infectious bacterial disease came late in the 19th century, and comprehension of viral infection afterward. Not early in the 19th. The real upswing occurred in the 20th century. Comprehension about vitamins and essential nutrients is also largely 20th century, after nutritional improvements from improved, higher productivity farming in the late 1800’s.

          And so the point about timing seems to me to be rather later than you suggest. And this also applies to synthetic medicines. Yes, there were synthetic toxic heavy metal antibiotics even in the 18th century, but they were highly problematic, somewhat ‘heroic’. (Aspirin came near the turn of the 19th/20th century. German and other chemical synthetic capabilities truly bloomed in the 1870’s and afterward, not early in the 1800’s) Medical practice of the early 19th century has been termed ‘heroic’ because of the extreme measures still being employed such as bloodletting, and purging of the digestive tract, and things like caustic black mass, hardly scientific. The many quacks in operation in the early 19th century seems to me to indicate that broadly speaking, medicine was not very scientific at the time. People didn’t understand much about the immune system in the 19th century. Thus the question of timing.

          The distinction between medical science and scientific medicine is actually quite simple. The medical science is the actual research and discoveries, while the scientific medicine is the approved applications resulting from the science. Medicine is a highly conservative field, and understandably so. Getting cutting edge therapies and diagnostics into practice sometimes occurs rapidly, but it isn’t normal. Time lags of years (sometimes decades) in introduction of therapies is normal. (Operations are a different matter.) It takes a long time for therapies to get through the phase 1, 2, and 3 trials. There are differences of course for approval of treatments for life threatening conditions versus non life threatening circumstances. The time course for approval in non life threatening situations and chronic applications is longer and more difficult. And so the distinction seems to be quite plain in practice.

          Some safe (by clinical trials) immuno-therapies I am aware of, discovered/developed in the 1980’s and 1990’s are as yet unavailable. To me, the distinction is quite clear cut between medical science and scientific medicine. It isn’t Brown’s definition.

          In any case, Dr. Brown’s book is interesting, if sometimes a little opaque. Much more interesting than anything I could write.

        • Michael Gorback says:

          Tim your scope is too narrow. For example, morphine was isolated from opium in 1804 and hit the market in 1817. Injection of morphine began in the 1850s.

          There were more types of surgeries being done than you give credit for in the 1800s.

  29. Paulo says:

    (Doctors went on strike to try and stop single-payer healthcare in Sask. Tommy prevailed and waited them out. I seldom hear any Doctors these days in Canada trying to opt out. Rarely. Those that do push it usually own their own surgery clinics, and if they bill privately they lose the right to bill the public system. They can’t have it both ways)

    From Tommy Douglas:

    “I felt that no boy should have to depend either for his leg or his life upon the ability of his parents to raise enough money to bring a first-class surgeon to his bedside. And I think it was out of this experience, not at the moment consciously, but through the years, I came to believe that health services ought not to have a price tag on them, and that people should be able to get whatever health services they require irrespective of their individual capacity to pay.”
    T. C. Douglas, The Making of a Socialist, p. 7.

    and: “Saskatchewan was told that it would never get hospital insurance. Yet Saskatchewan people were the first in Canada to establish this kind of insurance, and were followed by the rest of Canada. We didn’t have Medicare in those days. They said you couldn’t have Medicare – it would interfere with the ‘doctor-patient relationship’. But you people in this province demonstrated to Canada that it was possible to have Medicare. Now every province in Canada either has it or is in the process of setting it up.”

    “It has been said that a country’s greatness can be measured by what it does for its unfortunates. By that criterion Canada certainly does not stand in the forefront of the nations of the world although there are signs that we are becoming conscious of our deficiencies and are determined to atone for lost time.”
    Comment at the Dominion-Provincial Conference, 1946

    • Michael Gorback says:

      Paulo, I see the problem as a conflict between two opposing forces.

      As a society we don’t want people to lack necessary care. On the other end of the spectrum, centralized planning usually ends in tears. A free market is the single most efficient way to transmit price and value information throughout a system.

      Where any society ends up along that spectrum is decided within that society. However, you cannot simultaneously have a centrally managed socialist system AND cost efficiency. As we have shown in the US, a crony capitalist system doesn’t work either.

      Canadians may love their system but it’s a bug looking for a windshield and ultimately taxes will have to go up for it to survive. Similar systems in other countries are already experiencing the crunch.

      Canada’s problem will be how to fund a socialist system in a world that isn’t buying as much oil, timber, aluminum and other commodities. Canada’s marijuana business has already been hurt by US decriminalization. I’m not being snarky here – according to what I’ve read MJ has been a major export for a long time.

      It’s that old Thatcher thing about running out of other people’s money.

  30. Taco says:

    wow, you deleted my comment, so lame. I’m done reading and adding to the conversation as you can’t be trusted anymore after your heavy handed censoring, your just in it for the money like the rest, aren’t you? Your true colors shinning, you are a fraud!

    • Wolf Richter says:

      Insulting our authors is a good way to get your comment blocked.

      If you want to contribute to the discussion, and you disagree with the author, fine. Many commenters disagree with our authors. No Problem. But this is not the place to be nasty.

      • TheDona says:

        Thanks Wolf. So glad you are preventing this from going down the path that ZH has done.

  31. JW says:

    I am a UK national now living in France but spending months in the US. Most increases in national actual medical costs ( not insurances) are due to increasing aged populations, and rising costs and emphasis on the ‘sexy’ end of medical advancements. Whichever method of payment these common cost drivers affect most western nations.
    Single payer or the French derivative is much fairer to the general population in terms of coverage and costs. However its not perfect. Given a choice of sorts, I ensure I have good ‘travel’ medical insurance to get me back to France. There, rather than pay the 8% or so of salary/pension on social charges related to health costs I have hospital only insurance cover with a reasonably high deductable and pay cash for everything else. By far the most economic solution.
    Great article and discussion.

    • Michael Gorback says:

      JW that works for you but can everyone in France do it?

      • JW says:

        No, the vast majority pay 8% or so social charges for 70% of total costs. They usually have top-up insurance for the remaining 30% ( not expensive).

        • Michael Gorback says:

          I see. So this is a workaround that you can exploit but it’s not a large scale solution.

        • JW says:

          There is no reply button on your response, so here goes.
          I described my own economic solution. However a single payer solution of 8% social charge covering 70% of ALL medical charges beats the US system hands down. Especially when the service delivered is rated by most as ‘best in class’. The French health system may not be perfect, but it combines localised management of services with a high level of delivery with a relatively low cost.
          You may be surprised by my statement about ‘localised management’ when applied to anything French, but that is because many people misunderstand how France is managed.

  32. Hank says:

    Hey guys this is called Capitalism. According to people like Ron & Rand Paul the system will take care of cheats and charlatan’s. That is of course if they are not protected by the politicians and the system. Money rules. LOL

    • Michael Gorback says:

      To be precise it’s crony capitalism, where instead of building a better mousetrap, which would cost a ton of money in R&D and capital outlay, you opt to purchase favors from the government, such as getting subsidies for your mousetrap or regulations that prevent others from building a better mousetrap. Purchasing favors from the government is far less expensive.

      The 99% can’t do that. Who can afford to make a PAC contribution big enough to buy lunch with a Senator?

  33. CrazyCooter says:

    OMG. 93 Comments at the time of posting.

    I was just going to say that I live in literally the highest cost health care sector in the US. I paid 1k bucks each (wife and I) for physicals in 2013. I haven’t been to a local doctor since (ex emergencies that require stitches – and I am healthy and have very good insurance, but isn’t’ that the problem).

    In 2016 we had full on physicals at the French Vietnam Hospital in Vietnam and were both out the door for 500 bucks. This included blood work, ultrasound, chest xrays, and a host of other tests – and I spent about half an hour with the doc writing up the report – which he signed. Saved just as much on dental (forget the institute name) and optics (we were in/out in 45 minutes with new glasses each).

    Wonderful trip, during Tet Holiday, and brought home lots of their amazing coffee (another source of savings).

    Oh, and I called my insurance company prior to the trip and they said everything should be covered 80 to 100 percent. Doing claims this week.

    I will read this thread tomorrow when I have time – but if you have high cost (e.g. deducible) and plannable health insurance stuff – turn it into a vacation and come out ahead.



  34. AJBaer says:

    Had half my thyroid removed a couple of years ago. When I complained about the $25,000 bill to my ENT, his response was “isn’t insurance covering it?” I called the hospital and they cut the bill in half.

    Went back to the same doctor for stuffed up sinuses. Thinking allergies. After talking, he runs a scope up my nose and diagnoses inflamed sinus. Prescribes a $10 medicine. Procedure took 5 minutes. Got the bill for $500.

    Yes, our healthcare system is broken.

    • Michael Gorback says:

      If this was covered by insurance there will be likely be a contractual write-off. If you paid cash why didn’t you talk about the price first, or even after you received the bill?

      Didn’t you learn anything from your experience with the hospital? You have to ask!

      This is a painful experience but it’s exactly what the country needs – awareness of how screwed up the system is. People have been disconnected from the cost for too long.

  35. Oneyedjack says:

    My doctor said the D E A targeted a pain management doctor in the area for minor infraction.(soft target)P M doc lost his licence and practice,now my scared doctor said D E A said they want ALL pain users on gov approved Obamacare placebo next year.Any one wanting a prescription will have to come in every day to doctors office! Doc said D E A wants all off pain medication-evidently D E A is everyone’s new doctor Doctor said D E A given millions to target(soft targets) pharmacists,doctors,and pain sufferers.Horror stories all over the country.Does this all tie in with Obamacare,right to die nightmare?

    • Michael Gorback says:

      Oneyedjack, I have worked with law enforcement at federal, state, and local levels. They have limited resources and only cut the tallest blades of grass. They once called me and asked if I would testify for them for free because the doctor they had lined up was doing it for free if they would pay his airfare. They couldn’t afford airfare from Dallas to Houston.

      Before they can take someone down they have to run multiple undercover cops through the clinic to document what’s going on. In one instance I know they infiltrated an FBI agent onto the office staff. I review prescribing cases for the medical board. You have to color way outside of the lines to get busted.

      There is no placebo program and there is no way in the world that they can make you come in every day like it’s a methadone clinic.

      The DEA’s policy is that you can prescribe however you want for a VALID MEDICAL PURPOSE. Most of the busts are for non-therapeutic prescribing” also known as selling prescriptions.

      Your doctor needs to check snopes.com more often. Believe me, there are no DEA agents hiding in the bushes outside your doctor’s office if s/he is legit.

  36. Oneyedjack says:

    Michael G Thank you for the reply.My doctor was very sincere and made it very clear next year patients will come in every 7 days for pain opiate prescription then every day.This will be new rules by D E A. Also doctor said non opiate in place of pain pills(sorry,I called it a placebo,being facetious ) Said D E A wants all patients off pain meds. Do not feel D E A has any place in valid pain management between patient and doctor,and they have gone too far in intimidation tactics with patients,doctors, pharmacists.Why?

    • Michael Gorback says:

      All of the things you were told about DEA’s plans are completely false.

      First of all none of those things have been proposed by the DEA. Secondly the DEA does not have the authority to regulate the practice of Medicine. The DEA is only allowed to enforce what’s laid out in the Controlled Substances Act.


      If you read the document on their website you will see that they lay this out very clearly in black and white and they say it more than once.

      The DEA does not function like a State Medical Board and cannot regulate the practice of Medicine. That means they don’t make rules about dosages, types of medication or refill intervals.

      In the document referenced above they actually say that they will not provide prescribing guidelines not only because they don’t have the authority but because it’s impossible to construct guidelines that will fit every situation.

      Each state can develop its own guidelines and policies through the legislature or through the medical boards. For example the state of Washington has guidelines for primary care doctors regarding dosages at which they recommend a referral to a pain specialist.

  37. Clinic in rural Ohio says:

    Primary care offices LOSE IT ALL. The doc who wrote this article perhaps is unaware that it is ILLEGAL to offer cash price services to a patient with an insurance plan you have a contract with. Just try it in Ohio, you are toast. Better yet is the math: high deductible, no co-pay and you are obligated by the insurance plan to provide care = equals bankruptcy for primary care practices….plain and simple.

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