I am David Belk. I'm a doctor who has spent years trying to untangle the mysteries of health care costs in the US and wrote a website exposing much of what I've discovered AMA!

The owners of Reddit should step up and do something really important for this society that will cost them very little, simply by leaving this post at the top of the Reddit website for a few months, instead of "featuring" other irrelevant post that they like to feature on top. Do it Reddit, do it for this nation, this guy is exposing a lot of things and is showing us how to deal and pay for health issues and most importantly how to impact the healthcare community in a huge way.

EDIT: Who ever gave me a month of reddit gold thank you! I was never expecting anything from anyone for just typing a comment i felt needed to be said, thank you so much, I'm not sure what to do with it though :/

Gee, thanks. I'm not sure I could answer question all month though. I'm a slow typist and I'm afraid my fingers would probably fall off.

I live in the UK so I don't know much about your healthcare system, but I'm curious: the general consensus over here is that people in the USA might be avoiding going to see medical professionals due to the costs. Do you think this is true at all?

Yes, if you don't have insurance it's a minefield. If you do have insurance you're still not always safe. Just watch this and see for yourself: https://www.youtube.com/watch?v=vNJ6DYCaG-4

This makes me feel seriously ill to watch. Bad enough to be ill but then to be ripped off by the ones who are supposed to help look after you, that's unbelievable. I hope this changes soon.

I'm trying

You seem to be doing a great job :)

Thanks

What would be your ideal healthcare system? I.e. What country do you believe has it "right"?

Every possible system will have its flaws. What makes our system so unique is that it seems to found a way to have all the flaws of every other health care system while avoiding any of the benefits.

Seriously though, I think one way to improve our system is to cap how much hospitals can bill. It's been done in Maryland since 1977 and works fin there. It won't fix all of our problems but I like to approach problems one step at a time.

Here's a blog I wrote about it: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

What do you think of this PBS Frontline episode that examines five different national health care systems? http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

I hope I'll have time to watch it later, thanks.

Why do you think price caps would work on a national scale?

I actually think it would be better to do it for hospitals State by State partly because we already have a model for it in Maryland and also because the US Congress couldn't pass gas let alone an effective bill right now. It's also easier to get things done at the State level

our system is messed up in a ways, but to say that their are no good things about it is sorely misleading, and it sounds like more of a political statement than some truths..

OK, I was exaggerating a bit but I couldn't help it. Anyway, it was kind of funny.

My extrapolation of the way hospitals work is that they'd react to a cap by doing the shittiest, half-done job, bill you for the full amount, and run you right out the door...

Also superfluous billing items. Yeah he came in for a mole removal, let's add a full urinalysis, blood work, and semen analysis, 5-day hospital stay, 12 different medications, 8 "expert consultants", and full-body x-rays.

Well, that's not how it's working in Maryland. Also, you might want to read this to see what hospitals do now.

When are you doing to hire a professional web designer to make your website more appealing to read and navigate through?

You have to understand, I'm not getting paid for this so, whatever I spend on it comes out of my pocket. A few people have written me to offer help but they live in other States making it a bit more complicated.

PLEASE upvote this so David can see it. David, I'm a co-founder and chief designer at Medko, a startup that helps people find quality and affordable care outside of the US (http://www.medkohealth.com/). I'm also a bay area native.

I saw one of your comments about the quality of your site and would love to talk with you about offering my web design services, free of charge. I'm confident we can coordinate enough via Skype and Email to get you something much more professional.

You can contact me at: dev @ medkohealth (dot) com.

Michael

email me at the website.

What can I do to help you?

Post my site and my videos anywhere you can. If you show people the three minute videos I made on, for example, the cost of generic medications you can get them interested. Those videos play well on a smart phone so you can show them to anyone.

I would to tell you my situation, then you could comment on it.

Several years ago I had to have an umbilical hernia (I was an adult) repaired. I did not have health insurance of any kind and so paid cash for everything.

So, in my state, no specialist or surgeon will see you unless you first get a referral from a GP or family care practice....

It was obviously something that required surgery, since there was this soft fleshy bit poking in from the side of my navel; I had already diagnosed myself before I was able to get to my GP. I go in, tell him I think I have a UH, he pokes and prods for a few minutes ... yes, he agrees. ** Bill: about $140 (first time visit adds about $75 over a regular visit).**

Surgeon's visit - I pay one price, $850 or so, for all consult and the surgery itself. Note that the surgeon is the guy who is most responsible for the patient outcome in all this! I think I visited him 1 or 2 times prior and 1 time after surgery.

I have a prescription for an abdominal CT scan. I call around - the 2 hospitals in the area want between $2750 and $4000 including interpretation.

I remember an outpatient imaging place that my wife used a while back for an MRI - we call them, and find out that one of the above hospitals, BOUGHT THEM OUT AND THEN SHUT THEM DOWN - why did they do that, doesn't make sense or does it???...

But, they have 1 independant place that the hospital did not buy, still running in a depressed area 3 hours' drive away. Their price? "Well if you pay on the day of service with cash or credit card, the price is $264."

It gets better - the owner of this imaging clinic, who sold off the other branches to the big hospital? He is the Head of Radiology Deparment at a well-respected hospital about 1 hour away. So the hospitals bought him out, only because he was undercutting their prices!

CT scan in hand, surgeon ready to go ... I check out surgery prices at the places the surgeon has privileges at...

Hospital 1 - flat fee, about $3500 Hospital 2 - won't give me a price over the phone - because they charge by the minute! And it will matter if the OR is used for 45 or 55 minutes as to the price ... note how stupid this is, because ORs are not utilized anything near 8 or 12 hours a day, continuously

** Shiny-new Surgical Center, cleaner, less hectic, nicer nurses, etc. - $1800, but, "oh, if you pay cash or credit card on the day, the price is $1200"**

Anesthesia - $660 (note: almost as much as the surgeon, just for a nurse anesthetist!)

Add up the difference between what I paid cash for and what the "retail price" was ... to me, the shocking 10X difference in abdominal CT scan makes you wonder, "what exactly, is a fair price for CT scans?"

I welcome your comments on any part of this.

Your story is exactly why I'm doing what I'm doing. Health care in this Country is a scam that disproportionately a scam affects the uninsured and it needs to stop.

I have MS so I take a specialty drug called copaxone. With my insurance my copay is/would be over $6000/month. That's gone up about $1000 in the last year. Since there is no way that amount is even remotely affordable I'm able to qualify for the copay assist program. That brings my bill to about $35/month. The organization that admins the copay assist is the manufacturer. So, do they write off the balance? Their reaping in money from my insurance and essentially waiving the cost to me. How is this? Are taxpayers having to foot the bill? How and why is this happening? Do you know if obamacare will address this issue is any way?

No, the drug costs the pharmaceutical company about $50 to make so they make more than enough money to be charitable at times.

This is very relevant to me. Can you provide some source material on drug manufacture cost vs. price? Especially for Copaxone?

No, that's a proprietary secret but it's only a polypeptide made with four amino acids so I don't see why it would be very expensive to make. Most low molecular weight molecules are very inexpensive to make.

I have a couple of patients who worked as chemists for pharmaceutical companies and they confirmed that a couple of kilograms of most standard medicines can be manufactured for a few dollars.

About the only drugs that are expensive to make are the biological agents like monoclonal antibodies. How expensive? I don't know and we'll probably not know for a long time since none of them will likely be generic for decades, if ever.

What measures to do you take so as not to be killed by the government?

I live in a city that has no tall buildings so snipers can't get me. I also don't have a very regular schedule so it's hard to predict when I'll be going anywhere.

I have year-round sinus congestion issues. There is a nasal spray that almost completely eliminates my symptoms (heavenly!) but it would cost me about $140/mo to purchase it. My insurance doesn't cover it and there's no generic.

What's your take on this? It's not life threatening, so should I just live without? Do you think that it's reasonable for a drug company to charge that price with the help of the government (preventing other companies from producing the same drug)? Something else?

Which nasal spray do you use? Also, I think the drug companies do abuse the patent laws. They'd make plenty of money if they sold you nasal spray for $20 but, in our system, drugs are sold at the maximum price the market will bear because so many people use insurance to buy them.

Veramyst is the one that really works.

Veramyst is fluticasone. It's the same active ingredient that's in flonase. Here's the price at costco: http://www2.costco.com/Pharmacy/DrugInfo.aspx?p=1&SearchTerm=f&Drug=FLUTICASONE

It's not often I get to school an attending and get away with it. So here goes. Veramyst is not Flonase.

Source:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3147057/

I admit I just googled Veramyst because there are dozens steroid preparations out there. I'm assuming then Flonase didn't work for you?

What it's the most earth shattering discovery of your investigation?

The fact that so few people in health care seemed to care about what I found. I thought they would find it helpful but most doctors really don't seem to want to know any of this.

You are fucking with their business model. I doubt they will thank you for it.

Agreed.

David Belk, thank you for the work you are doing. I have seen your work in the past and even cited it in a paper I wrote.

If I ran for President of the United States, could I hire you in as one of my advisers if I got elected? If you accepted, what would be some of your immediate policy advice (list a top 3 or a top 5...I know you're probably short on time. If you can give a super long and thorough answer, that'd be great)?

I'm not sure I'd like government work but, thanks for asking. Anyway, I'm definitely in favor commissions that cap how much hospitals can charge. It works in Maryland and, quite frankly I can't think of a better way to reign in the insane billing practices of most hospital. Here's a blog I wrote about it: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

I also think that the price of all medications and medical services should be easy to access the same way the price of everything else we buy is.

Also all anti gouging laws that apply to every other industry should apply to health care. I don't see why we should live in a Country where auto mechanics are expected to be more honest about their business than doctors or hospitals.

Is there anything that can realistically be done to stop the monopolization of medical supply companies? Part of the reason hospital visits cost so much is the fact that the supplies are ridiculously overcharged by the few approved suppliers.

Monopolization is a problem we have in most industries. In health care it's worse because there are no anti-gouging laws as well. As far as hospital costs are concerned, I've written a lot about them. You might find this interesting. It's an analysis of the financial records for nearly every California hospital over nine years: http://www.truecostofhealthcare.org/hospital_financial_analysis

If you were given full power to rewrite out healthcare system from the ground up as you saw fit, would you do something completely new? Mix and match of different countries?

I'm American, was recently travelling in New Zealand and Australia for 3 years. My house mate hurt himself on a rock surfing once and I drove him to the hospital, they did tests, gave him pain killers, they thought he ruptured his kidney. After 7 hours he left (he was fine, week off work with painkillers) and didn't have to pay a dime. I should point out we were both long term travelers, we were working full time and paying taxes, I think it's different for people just passing through.

Anyway, I've broken my arm twice and have seen first hand what a clusterfuck the American medical system can be, and was amazed at how awesome it was in New Zealand.

Well, realistically, it would be a bit hard to redo the entire health care system in a Country this big from scratch. My first, and most important goal, is to get everyone to understand the system we have. I feel once everyone understands health care costs, how they are paid becomes less controversial. A major problem in the health care debate is that everyone is getting scared off by enormous prices that have no bases in reality

Can you see Obamacare leading up to Universal Single payer? IOW, is it possible that Obama re-packaged RomneyCare as a stepping stone to achieve the eventual goal of necessitating a single payer system?

It's hard to say. It would more likely lead to a system similar to what they have in Germany where the private insurance companies are highly regulated. Our problem isn't so much public vs. private for payers. It really boils down to the fact that health insurance companies operate like protection rackets because billing charges for most medical services are so high.

Is there a way to ELI5?

Whenever healthcare is talked about, the concept that we are the "only western" or "only 1st world" country that exists with this ass-backwards medical system is always thrown around... How come our government/population is so complacent with this standing? It blows my mind that that statment can be so casually spoken without ANYONE being embarassed and subsequently affecting any change!

Here in America, we've always had issues with progress. Remember, we're also one of the few Countries that hasn't adopted the metric system and we still use pennies for some strange reason.

What are your thoughts on the subject of improperly tested meds being rushed through their clinical trials by an FDA that accepts "consultation" fees from the same drug companies they're supposed to be monitoring? How often would you say dangerous drugs go to market without proper testing or necessary rejection, and how many lives are affected?

That's a good question. Part of the problem is that the FDA is underfunded. As far as drugs getting "rushed" that really started with the AIDS epidemic when a lot of activist were complaining that anti HIV medications are taking too long to get on the market. Streamlining the process improved the situation for getting some urgent lifesaving meds out early but, as with any relaxation in policy, it opened the door for abuse.

Mostly, the problem isn't that drugs are rushed through the FDA but rather the research and the evaluation of the drug research is conducted mostly by drug companies and they've learned to manipulate the process well. Here's an article that addresses that problem:

http://blogs.scientificamerican.com/guest-blog/2012/09/23/can-the-source-of-funding-for-medical-research-affect-the-results/

I have an underlying medical condition- Ulcerative Colitis. Got diagnosed about 6 years ago. Its fairly mild, controlled by daily meds. I'm under a low-key but always available 'watch' by my docs and nurses, and I can turn to them at any time. Case in point: I had a little bit of "gastric flu" last week for 4 or 5 days, and a bit of a lazy gut for a day or so afterwards. Got some cramps because I couldn't pass wind, called my docs to get an emergency appointment. In there an hour later, and he confirmed that all was well.

Now, I'm lucky because I'm in the UK, and this is all paid for out of general taxation. I'm a taxpayer. We get a better deal all round because of the economy of scale that a country buying its healthcare from providers can give. Its not perfect, but it sounds about 1,000,000% better than in the US.

What I've never understood is why those who defend it say that the American system is democratic, that other nations are 'socialist' (as though that's degenerative). Why can't America just see that they have a system that's designed to bilk them?

Whenever a system is inefficient, a lot of players will make huge amounts of money on the inefficiencies. Those players will do anything they can to prevent change

What can be done, realistically, to change the view of healthcare in the U.S. and to get people to wake up and make a change? Also, did you see Michael Moores doc. Sicko, your thoughts on it?

I saw sicko. Michael Moore was wrong on a few points but did a great job of exposing how intentionally evil health insurance companies are. I guess the answer to your first question is the focus of my crusade. People have to know exactly what's wrong with our health care system before we can really fix it.

Mind expanding on what you thought was wrong?

It's a bit hard since I saw the movie several years ago. I remember thinking at the time that I would love to sit down with him and explain a few things about our system that only someone on the inside would understand. One example is how the role of hospitals in treating sick people has been shrinking in this Country. It's not entirely because people are being kicked out too early (though that does happen unfortunately). It has more to do with the fact that hospitals were over-utilized tremendously in the past. I wrote an essay about that a couple of years ago. I should say, I wrote the essay before I got a hold of all the financial records for California's hospitals so I know more now but I think it's still worth reading if you like: http://truecostofhealthcare.org/yahoo_site_admin/assets/docs/Bankrupt_Hospitals.211200419.pdf

What made you decide to do this research?

All of the deceptions and misunderstandings at every level of this business were driving me nuts so I felt I had to do something about it.

Do you think patients or potential patients should negotiate prices for procedures. How does one go about it.

It's possible to negotiate prices and get deals on elective services and outpatient tests and procedures. It's not realistic to think you could do it in an emergency though. That's where people get hit the hardest.

Also for complex problems like cancer treatment, there are so many players involved in your care you couldn't possibly arrange a deal with all of them separately. And trying to do this while going through surgery, radiation therapy and/or chemotherapy would truly be a nightmare

How much of the cost of health care is attributable to the fact that insurance policies, for lack of a better way to put it, are trying to nickle and dime you at every step of the way? In other words, at what point do the bureaucratic costs of administering all of these various plans, all of which are ridiculously complicated, exceed the cost savings of denying care?

It's more complicated than that. The short answer is that insurance companies deliberately obscure how much health care costs so that they can function more like a protection racket. That's where the money is and that's why everything in health care is so confusing. Confused people are easier to take advantage of.

Do you believe universal health-care to be a possibility in the US in the future?

If you mean single payer, I'm skeptical our US Congress would ever allow it to happen.

Yeah, sorry, I was thinking single payer.

You would like it to happen, though?

I wouldn't be against it happening I'm just not holding my brealth.

This one of the reasons I think the US needs to break apart into a handful of smaller countries. If this happened, certain parts would very likely implement European-style single-payer systems and finally make some progress, without being held back by the other regions.

We tried that in 1861 and it didn't end well.

Are we overcharged? Is it true doctors just write prescriptions to get more money? What is your stance on vaccines for babies? Are they more dangerous to get then to not get like some people claim? Edit: I apologize, I submitted the same question twice. No need to answer twice.

Yes, we're overcharged considerably for most medical services. Doctors don't normally get paid to write a prescription. Vaccines have saved millions of lives and are well worth any slight risk they might pose.

Maybe a stupid question, but something I always thought would be obvious:

If end-of-life care accounts for so much of the cost, why not make living wills mandatory? (Could be implemented at every point of healthcare interaction, via the IRS, etc).

Death panel crazies wouldn't have to worry either because someone could still specify that they want all possible methods used to keep them alive, but I suspect that most would not.

This would also solve the problem of family members keeping them alive when they don't know what they actually want.

To be honest, I've not found living wills to be of much help. There too long and complicated and usually not available when they're needed. If a patient tells me they don't want CPR I make a note of it but, unfortunately, that note won't leave my office. Communication in health care is currently somewhat slower and less efficient than the pony express. What's more, EHR systems have made it far worse since none of them can communicate with each other.

Would a better reform of healthcare in the US have been to rein in costs rather than to make the changes the Affordable Care Act is attempting to make?

Our health care system is broken in so many ways no one solution will fix everything. However, the focus of my website is actual health care costs because so few people seem to understand them. As far as reigning in costs are concerned, I have proposed an idea that I think will help. Here's a blog I wrote about it: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

That's a great idea. For the motorcycle accident you referenced in the article, what would the cost have been in the Maryland hospital system, instead of the Sacramento, CA hospital at $31613?

Also, would it stand to follow that the monthly premiums paid by healthy individuals under the Affordable Care Act mandate would be substantially lower if the Maryland system was enacted nationwide?

It was a bicycle accident and it would probably cost about $3000 because they did several CTs to make sure he didn't break anything. as for your second question: Absolutely

Is insurance strictly needed? (There are many things we buy that do not involve insurance companies.)

Is it not in the interest of insurance companies that health care becomes increasingly expensive to firstly, scare people into buying insurance and, secondly, justify high premiums?

It's needed for emergencies and high priced things you couldn't afford on your own. Most people would have a lot of trouble paying for a new liver if they needed one.

I will admit I am lenient towards conservative, and I obviously dislike Obamacare. Everywhere I look everyone keeps saying "single payer system."

My problem is, I don't trust the government enough with all the scandals, corruption, and no money to pay for my insurance. Does the single payer system have some way to avoid that? I don't want it to end up like the IRS and targeting people based on their political views.

You can't trust the government much but you really can't trust unregulated corporations either. Bottom line is you eventually have to trust someone because you'll never be able to remove you own appendix.

Have you ever watched John Bergman's videos on You Tube? If so, do you believe "If diet is wrong, medicine is of no use. When diet is correct, then medicine is of no need." ?

A good diet helps but it won't solve every problem in health care. Some people will live the healthiest lifestyle possible and still get sick while others can live like Homer Simpson and die in their sleep at 95 never having seen a doctor. Life isn't fair.

many people rely on medicare, now doctors are starting to stop accepting medicare patients. what is the easiest political solution to this?

I don't know. Medicare is one of my highest payers so I can only assume these doctors don't understand how they get paid. That's more common than you think BTW: https://www.youtube.com/watch?v=bZCYblB3kHk

Are you familiar with the recent conflict between the FDA, DEA, and drug manufacturers over amphetamine quotas (which has caused a significant spike in the cost of Ritalin and generic equivalents)? Do you have any thoughts on what could be done to prevent situations like it?

I know the DEA has been cracking down on the over-prescribing of many controlled substances and they're probably going a bit too far. I don't know that that, per se is what caused the price of ritalin to spike. If it is then that's news to me.

What role do you see mhealth or other wearable technology in driving down costs?

I don't know. What is it?

Hello, and thanks for doing this AMA, I'm a premed student who's studying for the MCAT at the moment.

Do you have anything you'd like to impart onto students who are looking to get into health care, given what you know of its financial hardships?

That's tough. I went to USC medical school in the 90's (California not Carolina). The year I graduated (97) USC had the dubious honor of having the highest tuition for a medical school in the Country. It was just over $30,000 a year. Now I hear Public medicals schools cost about that much. It's insane by I can only address one scam at a time so University tuition will have to wait.

No offense, Dr, but in this age of web development, your site could really do with a visual overhaul. I am guessing that thousands more people would read the information you are trying to present with some simple upgrades to the way in which you've constructed your site.

Or just convert it to a WordPress template and call it a day. A couple of pictures, graphs, charts, etc and you're good to go.

As it stands, its pretty awful and uninviting.

(I know this is an AMA, but I would really like for people to read what he's wrote and form their own conclusions, and I believe reformatting would do a great service to the work he's performed).

I know, I've been told that often and I'm planing on doing that some day. The problem is I'm not all that good with computers and I'm doing this mostly by myself (though my receptionist, Heidi, helps a lot)

For a half second i thought this was about Doctor Who. :(

Sorry, his AMA was yesterday.

How can QALY be used in this country to reduce the cost of health care?

I don't know. I'd have to look into it a bit.

I'm from the UK so only know about the NHS, which is heavily overstretched but in my opinion a very good healthcare system. From my very limited knowledge of the US system, it seems so messed up that in a western country that one hospital admission can bankrupt a person if they are not insured, which leads to patients not getting health issues checked and causing further distress to the family during medical emergencies.

What do you think of the British system(pros and cons)? And what would the implications be of implementing the British system in the US?

We'd be better off with the British system but it's not going to happen here. I address that here: https://www.youtube.com/watch?v=bBJAnrBc9n4&t=10m3s

What do you think about doctors' salaries in the US? How should they be changed, if at all?

I'm happy with my salary.

Since you're a doctor, how many "kickbacks" have you given other doctors?

None so far.

How do you feel about patents and how they are used in pharmaceutical firms? These firms spend billions to find a drug that help save lives. Should they be able to sell their product at a higher price?

Well that depends on what you mean by "a higher price". $70,000 a year for glivec is a bit steep. Also, our patent laws are way too generous. The pharmaceutical companies can extend or renew patents on really flimsy grounds. Asthma inhalers may never go generic because, every time a drug company changes the design of the inhaler a bit, they get a new patent. The medications in those inhalers have been off patent for years.

Hi Dr. Belk!

What do you say to the proponents of cutting physician salaries to reduce healthcare costs?

Regardless of its potential impact on overall healthcare costs, do you think that U.S. physicians paid too much? If so, what can be done about limiting the opportunity cost of becoming a physician?

I don't think I really want my salary cut. The truth is, physician fees are a small component of overall health care costs. If I worked for nothing it wouldn't affect the amount paid to hospitals, pharmacies, pharmaceutical companies, labs and, of course, health cares biggest offenders, insurance companies. That's where most of the money really goes. There are doctors who are truly scamming the system and it's a problem. That said, it's far from the biggest problem this business faces.

do you like hamburger

Of course, who doesn't?

What is your stance on getting your baby vaccinated? Some people think it is worse to vaccinate your baby then to not. What do you think?

Both my kids are vaccinated. I refer you to Penn and Teller: https://www.youtube.com/watch?v=RLcOz4EKrxg

What are your thoughts on people who abuse the system? I work in health care, and it seems to me that the people who are the most abusive to our current system, are the people for whom everything is subsidized. If we simply give everything away for free, what are the incentives to lead healthier lives?

There are people will abuse everything and health care is certainly no exception. The fact is that the people most likely to abuse any system are the ones who know how to get their way no matter what. Restricting access to anything usually does more to shut out those who reasonably need the service. The neurotics are the ones who always get through no matter what.