I am David Belk. I'm a doctor who has spent the last 5 years trying to untangle and demystify health care costs in the US. I created a website exposing much of what I've discovered. Ask me anything!

Did you ever feel like throwing your hands up and quitting?

Every other day.

I work in a personal injury firm and we negotiate billing statements down on behalf of clients. It seems doctors/hospitals are eager to lower a bill if they know they are actually getting paid.

Do you think the average person getting treatment should be able to negotiate their bills down in a similar fashion? Also, do you think doctors/hospitals are willing to lower bills because they themselves are aware of how inflated their costs/prices are?

It's not whether you can negotiate a bill dow, it's by how much. Most hospitals bill four or more times their expected payment for medical services. If you negotiate 50% off a bill from a hospital that normally bill eight times what the value of their services, you've been taken big time

Also, if you want a more extensive summary of my work, you can watch this 48 minute video I made last year called The High Cost of Collusion: Why Healthcare is so Expensive in the US.

Also, Check out my blogs at Huffington Post. Especially this one about a woman who was told that $41 worth of migraine medication would cost her $1,490 at Walgreens, or this one about a woman who was charged three times the cost of her chemotherapy treatment simply because her insurance refused to cover it.

Who is most invested in maintaining the status quo? Do you think the greatest obstacles to health care reform are these monied elites, or just inertia?

Yes, and that's exactly what I said in my conclusion:

Everyone in health care likes the idea of making our health care system more efficient and less costly, right up until it starts to impact their paychecks. So health care reform, of any kind, will always be met with a lot of resistance from inside the system. All of that money isn’t just wasted— it’s going into the pockets of a lot of people who will fight very hard to keep things as they are.

There is no shortage of good ideas for how we can reform our healthcare system. Nearly every other country in the developed world has a healthcare system that’s less expensive, more efficient and has better outcomes than ours. We could easily take all the best ideas from all the existing systems in other countries to create more efficient and effective ways to deliver healthcare in the US, were it not for the resistance each new idea would face. At least $1 trillion is wasted each year in our healthcare system, but the people getting that $1 trillion can use that money to fight reform at every turn.

Hi David!

I work in healthcare the care delivery side and we're also very interested in this. I have two questions.

First, what is your feeling on the ACA? Both in terms of its impact on cost, as well as just generally.

Second, what is your impression of Senator Sanders Health Care proposal, assuming you have formed of one?

Thanks for taking the time.

The ACA has had no real impact on costs. That's not what it was designed to do. I think Bernie Sanders is ver well meaning in his health care proposals. I just don't think it's realistic to expect Congress to scrap our entire $3 trillion health care system and start anew. Even if it were possible (which is debatable at best) Congress would never allow it. Here what some of I wrote in my conclusion on the history of health care reform in the US:

By the end of World War II, health insurance companies had grown large enough to have powerful lobbies. Harry Truman discovered this the hard way in 1945 way when he proposed a nationalized health insurance program similar to the one that was being implemented in the UK.

Private health insurance companies saw this proposal as a threat to their blossoming business, so they joined with the American Medical Association (AMA) in a campaign to defeat Truman’s plan in Congress. They attacked the bill by running a national campaign accusing Truman of trying to make the US a communist nation by giving us a communist health care plan.

The campaign worked so well that the bill was killed and the Democrats suffered a huge defeat in the 1946 mid-term elections. Truman recovered somewhat in the 1948 election, but he had learned his lesson: don’t mess with the health insurance companies. Health care costs were only about five percent of our GDP at the time and only about half of the US population had private health insurance but, even then, the insurance companies were big enough to take on the President and win.

By the 1960’s, 70 percent of working Americans had some form of private health insurance that was mostly provided by their employers. In 1962, John F. Kennedy attempted to broaden health insurance coverage to cover those who couldn’t get private coverage. This time, rather than go after the business of the private insurance companies, Kennedy decided to only address the people private insurance companies didn’t want to cover: the elderly, the disabled and the poor.

You would think that health insurance companies wouldn’t be bothered if the government provided a service they had no interest in providing, but that’s not the way it worked out. The health insurance companies perceived any competition by the government as a direct threat to their business, so they again partnered with the AMA to defeat Kennedy’s bill. This time they hired a famous B movie actor to help in their campaign. Ronald Reagan gave speeches throughout the US in 1962 warning Americans that this “Medicare” bill would be the first step toward socialism and would eventually rob us of all of our freedom.

Again, the campaign worked and Medicare was killed in 1962 only to be revived by Lyndon Johnson in 1965. Johnson had the largest supermajority of Democrats any President has had since 1937. In 1965 Johnson had 68 Democrats in the Senate and 295 Democrats in the House. Johnson was also rather famous in his ability to “convince” unwilling Democrats to go along with his plans, so he managed to get Medicare through Congress.

Since then, private insurance companies in the US have coexisted along side of Medicare in sort of a hostile truce. Private insurance companies have never stopped wanting to either eliminate or control Medicare. Jimmy Carter attempted to expand Medicare in 1980 and failed and, more recently, a Medicare expansion was attempted in 2009 that also failed.

Both Richard Nixon and Bill Clinton tried to provide universal health care in the US by making private health insurance more affordable and available, but failed to get any legislation passed. Barack Obama has been moderately successful in expanding private insurance coverage in the US, but that expansion has met fierce opposition from the health insurance industry.

So, Bernie Sanders isn't proposing anything that hasn't been tried before. The fact that a single payer system was recently killed in Vermont shows just how challenging that solution is to implement.

The question wasn't whether Sanders' plan is politically achievable (I agree with you, it ain't) but what you think of it. Simply put: if Sanders had a majority in Congress, would it be a good thing if he implemented his healthcare plan?

Oh, and thanks for the AMA!

Well, there is two ways of looking at that question:

Would we be better off if we had a NHS similar to the UK? Absolutely we would.

Is it feasible for us to dismantle our current health care infrastructure and rebuild it? Good luck with that.

The problems that would create are way too numerous for me to account for here, but I'll leave you with this thought:

Currently the private health insurance companies control, either directly or indirectly, roughly 70% of all the money that goes into health care (figure 2 of the link). A good portion of that (the ASCs) is completely unregulated (figure 5). Now, imagine how much damage the health insurance companies could do with all of that power between the time they're told they've been made obsolete (and therefore have nothing to lose) and the time our single payer system goes into affect (which would probably take a few years once the legislation is passed).

Oh, and if you think they would risk going to jail for anything they did to destroy our economy, then please tell me, when has that ever happened?

Doesn't that terrify anyone in the US? I mean, it doesn't matter what's best for you, you won't get it unless there's a profit in it. People who have a financial stake in things are the ones in control. There's nothing close to democracy there.

We're way past being terrified here.

When you say we're past being terrified what do you mean by that? Are we past it in the sense that we are angry, apathetic, even more fearful, or something else entirely?

How about just plain numb?

How could we improve price transparency and give consumers the ability to choose less expensive for.s of treatment in non emergency situations?

By forcing all medical providers to post prices. That includes pharmacies, doctors, hospitals, etc...

Also, insurance companies should by forced to itemize how much they pay to each type of provider. Currently, all medical costs in the insurance financial statements are simply lumped together as "medical costs" without any clarification.

I saw that my optometrist got $40 from my insurance for an eye exam, and out of pocket that would be $140. I would gladly pay $40 for an eye exam up front. Now that I have insurance through my employer, I have no motivation to seem out medical care that avoids insurance.

Did the USA just ruin business for all anti-insurance medical care?

That actually happened decades ago and here is the story behind that: http://truecostofhealthcare.net/conclusion/

In your opinion, is the current situation fixable or should we just move to countries that aren't treating it as a profit-machine?

Well I think it would be a bit impractical for everyone in the US to move to another country, so we had better fix it. I think the most realistic approach to fixing these problems, though, is to itemize each problem within our healthcare system and then fix them individually. That a major reason for my site.

Any and all sweeping legislation that tries to address all problems at once will be blocked in Congress because such legislation would cost too many people too much money. Congress would never approve such a thing.

That's a great point. Are you remotely concerned that BigMed is too big to fail or be reinvented?

Well, it would be rather catastrophic to have our entire health care system "fail" for obvious reasons. As I say in my conclusion:

Everyone in health care likes the idea of making our health care system more efficient and less costly, right up until it starts to impact their paychecks. So health care reform, of any kind, will always be met with a lot of resistance from inside the system. All of that money isn’t just wasted— it’s going into the pockets of a lot of people who will fight very hard to keep things as they are.

There is no shortage of good ideas for how we can reform our healthcare system. Nearly every other country in the developed world has a healthcare system that’s less expensive, more efficient and has better outcomes than ours. We could easily take all the best ideas from all the existing systems in other countries to create more efficient and effective ways to deliver healthcare in the US, were it not for the resistance each new idea would face. At least $1 trillion is wasted each year in our healthcare system, but the people getting that $1 trillion can use that money to fight reform at every turn.

This is why reinventing our system is so difficult.

I've always been super frustrated that my lifesaving insulin prescription costs upwards of $50 a month (depending on my insurance coverage), as a copay to my insurance, and hundreds of dollars without insurance, but someone wanting a non-essential drug (like viagra), pays $5 for the treatment of something unpleasant, but not life threatening. Do you see this trend ever reversing, so life saving drugs are more affordable?

Well, to start with, Viagra isn't covered all that often by insurance plans. I see it rejected all the time. Also, any policy that covers Viagra for $5 would also cover insulin for about the same copay. Viagra costs about $40 a pill (that's the cost to the pharmacy) and most forms of insulin cost about $20-$30 per ml.

I would like to note that Walmart has been selling over the counter Humulin insulin for $25 for 1,000 units for many years now. I'm really not sure how they do it. They only sell this to people without a prescription or insurance, though.

The retail(!) cost in Europe was ~16€ per 100mg. Generics (especially those from India) are at <1€ per 100mg.

Those $40 per pill seem outdated and overpriced.

Yes they are. In fact, you can even buy generic Viagra here for far less: https://www.healthwarehouse.com/sildenafil-20mg-tablets-generic-revatio-16564.html

Viagra costs about $40 a pill (that's the cost to the pharmacy)

How is that cost justified? You can order generic Viagra from India for a dollar a pill with no prescription.

Which brings me to my main observation: the level of price gouging for all drugs in the US is completely out of control. How can these problems ever get solved with this sort of profiteering happening?

Actually you can get generic Viagra here for about 60¢ a pill. It comes only in 20 mg doses so most people have to take 2-3 pills at a time

Hi Dr Belk, my father is a Gastroenterologist based in India and has been to the US quite a number of times for various reasons. As you know healthcare in India is way cheaper than US, and many times for the same quality of care.

What I understood from my conversations with him was, the American system, as in the protocols, staffing and processes are the main reason for higher costs. Eg. A stent in US is bought by the patient (not per se) and after its use is thrown away. In India, the stent is provided by the doctor and is reused (if possible). Similarly, in an American intensive care, there is an epidemiologist, physio therapist and many other "ists" I haven't heard before, ready to attend the patient. In India, the doctor to patient ratio is far lesser. Similarly the amount of disposables consumed are are also several times higher per patient in the US.

Doesn't these explain for the higher costs at hospitals (not medical care in general) in US?

I think unnecessary over utilization exists, but it's not the main factor driving up these costs. medical devices are also over priced in the US just as brand name medications are. The biggest problem we have (IMHO) is that there is no consistency whatsoever in the pricing of any medical service. That exposes everyone to being overcharged for inexpensive services.

Who/what is responsible for this mystifying tangle of costs? Hospitals? Government regulations? Pharmaceutical companies?

I think the insurance companies are doing what they can to encourage the confusion but, since nearly every player in health care is profiting from the confusion, most don't want to fix it.

Would capping medical malpractice claims have much of an effect?

No, and I establish that here: http://truecostofhealthcare.net/malpractice/

Do you think that the debt doctors go in to attend medical schools makes them more money seeking afterwards to pay it down?

If you read my section on office billing, you'll see that doctors themselves have very little direct influence on these costs. In fact, I make it very clear that most doctors have no real clue how much they get paid to see a patient.

That's not to say that their aren't doctors who are problems. This 30 minute video I made from a radio talk show I was on goes over some of those problems.

Which is more difficult: trying to untangle healthcare cost, or trying to untangle headphones after leaving them in your pocket for a while?

Health care costs. The healthcare system is quite a bit larger and the knots can be very difficult to find, let alone untangle. Also, a new set of head phones costs a couple of dollars if you can't untangle them whereas new health care system cost a few trillion dollars

Do you think, in general, US doctors get paid too much?

As a physician, I sometimes feels I'm overpaid, but alternatively, I did spend 8 years after college racking up large amounts of debt and not saving.

What do you think of the excessive cost of end of life care, ICU stays in the elderly, etc?

I often see the ICU being abused for excessive length of stays for people who, essentially, have no hope of a quality life, or those 90+ years old. I think that, DNR status should be default at 75 years old, and should be opted out of, as opposed to vice versa, where I'm obligated to intubate and provide highly aggressive care to every demented nursing home patient that comes through the door.

Most doctors in the US aren't really overpaid, though there are some huge exceptions: http://www.miamiherald.com/news/local/community/miami-dade/article1962581.html

If you have insurance, can you still negotiate the price you pay that's leftover on a bill after your insurance pays? I only had to pay 30 dollars to go see a specialist, but have to pay out of pocket 1100 dollars for an mri, so I'm wondering if I can negotiate that with the hospital.

No: http://www.huffingtonpost.com/david-belk/with-health-insurance-the_b_9657708.html

What do you think is the easiest, most non-controversial thing that could be done to help bring down costs in the short term?

Force all providers to post fair prices for all medical services.

What is your opinion on tort reform as a method to lower costs of healthcare?

I wrote rather extensively on tort reform in the third part of my section on medical malpractice. It has had surprisingly little effect on malpractice costs in most states, outside of Texas, and almost no effect on health care costs overall: http://truecostofhealthcare.net/malpractice/

For a state by state overview on malpractice costs and individual tort reform laws see: http://truecostofhealthcare.net/malpractice_statistics/

Hi Dr. Belk,

As a father of two small children, I have had a tremendous issue with the billing department for our Doctor (who is tied to a university hospital). Every single well child visit over the last 2 years (which is supposedly covered 100% by our insurance, and every EOB shows $0 owed) is partly billed to us. I've had mixed success in calling their billing department and our insurance company, but every single visit ends up with us receiving a $170-$300 bill. Some of them even get sent to collections.

What can we do here? Anything? Is the hospital justified in sending us a bill for these things?

It's tough. Your doctor probably has no clue as to what's being billed for his services. It's all probably being done by the University with no input from doctor. You could try finding a doctor who practices independently.

Are you funded? If so by whom?

No, I do this for free (so far).

Late to the party so I'm doubtful you'll see this but do you think the Surgical Center of Oklahoma (which posts prices for all operations) is a model for the nation?

It's hard to say because there is no other similar system to their compare prices to. They say "this is what we charge, take it or leave it." and, if you want to pay cash, they're the only game in town. That gives them a rather strange monopoly on their services.

Yeah, why did my families health insurance just drop us and now we have to pay 500% of what we were?

Because they're assholes.

What led you to this fight of yours?

It's a long story but, in general, I just saw all of this deception and confusion in health care pricing and thought I might be able to clear it up by getting some actual prices posted. At the time I though, if people could just see what these products really cost...

That was five years ago. It feels like an eternity. I never thought any of this would get so deep, or that such a seeming simply message would be so hard to disseminate. It's been a very long an interesting journey to say the least.

Would it make sense to outlaw employer provided healthcare and open it to the free market similar to other forms of insurance? Everyone would get their own policy for their needs. They wouldn't have to worry about things like hobby lobbys refusal to insure birth control and free market principles would allow users to switch to the plans that best suit their needs.

Edit : some other benefits would include not losing their insurance when losing or switching jobs or being forced to switch because their employer is switching and is getting a better deal with a new company.

Well, I don't see how you can outlaw employer provided health care. You could either eliminate the tax break for employer provided health care (good luck with that) or you could provide the same tax break to individuals who buy their own health care.

The biggest obstacle you'll have, though, is the fact that insurance companies would rather sell ASCs to employers than insurance. Individuals can't purchase ASCs, so health insurance companies have no interest in insuring individuals anymore

I'm a medical student who has doctors on both sides of the equation. One of them, a radiologist, says when the life and health of the patient is on the line, costs shouldn't matter. This was in reference to ordering an MRI when an x-ray wasn't conclusive.

The other side says doctors need to be aware of the costs to our patients. Starting with a cheaper drug that is almost as effective, limiting blood tests, etc. are things we need to do for our patients so they don't go into debt. I've seen this come into play in Australia, where there are tests on whether a shorter course of chemotherapy (that costs less) is as effective as a longer, more expensive course.

Also, how do you suggest doctors push back against CEOs of hospitals who want to have low readmissions, excellent outcomes, and cut-rate care?

Edited to add: Is the solution to start using cheaper PAs and NPs to deliver things FPs and PCPs used to do? You'll hear screaming on either side of the aisle.

Well, an MRI only costs about $400-$800 to run. I think most lives are worth more than that: https://www.youtube.com/watch?v=yQKmDGsNNV8

How many more lives would be saved if doctors were not controlled by insurance companies and were allowed to treat as they were trained?

That's impossible to say but, keep in mind, doctors play only a small role in providing health care in any system. We have no control over what hospitals, labs, imaging centers or other providers charge our patients. Even if all doctors worked for free, it would go far toward unraveling the control insurance companies have on health care.

I have a friend that is diabetic and low income. Most of my friends money goes to simply staying alive due to high cost of insulin and various other medications and lives in near poverty because of it. How can I help my friend? How can we be sure what they are paying is even fair? I honestly don't even know where to begin.

Does your friend qualify for Medicaid? Insulin is very expensive in the US no matter where you buy it. You can check out Walmart. I believe they still sell Humulin insulin for $25 a vial without a prescription or insurance. That's the best I can give you. Sorry.

What's your opinion on Martin Shkreli? He claims that he raised the price on Daraprim because it was no longer very effective (it was outdated) and raising the price would allow his company to create a newer/better medicine. His explanation seems quite convincing, is there any merit to it?

Shkreli is a strange phenomenon. On one hand, I think he did us a favor by exposing (in his own weird way) how ridiculous pharmaceutical pricing is in the US. On the other hand, nothing he did appears to have made any sense. He bought two drugs that almost no one uses ever and hiked the price so high that even fewer people will use them. I couldn't find any financial data on Turing Pharmaceutics filed anywhere with the SEC, so I'm not completely sure that he wasn't pulling some sort of con on his investors.

Why do healthcare providers take an oath to help people and then make higher profit margins than nearly all other industries?

Why do people think it is a mystery where high healthcare costs come from, it seems pretty clearly to be from greed and a lack of regulation?

The oath is a formality. "Greed and lack of regulation" are a bit too general a description to address effectively.

who will you be voting for this election/do you find their healthcare standpoint sustainable or practical?

I'm not sure I want to discuss politics on Reddit. Some of the people here get really insane about that topic. It's as bad as Facebook.

What does untangle and demystify mean?

Sorry if this question bothers you

Explain every issue in detail so as to help with finding effective solutions.

Does it make sense to just outlaw insurance carriers? Make everyone pay cash, every time? Facilities would be obliged to determine costs before services were rendered. Patients would understand costs before going in.

No, that would be outlawing a multi trillion dollar industry (which is impractical to say the least) and people do need health insurance in order to cover medical costs that most people couldn't afford to pay for themselves. We need to reform the existing system extensively, though, to get rid of all the current scams in health care finance.