Who pays the mortgage or rent on the land and building? Who buys the advanced medical equipment,
It used to be that private companies would rent theatres in the NHS over weekends. However these days most private treatment is done in private hospitals. As the private companies turn a profit without direct public subsidy I would deduce that the costs of the buildings and theatres must be covered wholly by the fee paid for the surgery.
who pays for drug and biotech R&D given caps on drug prices that remove all but a small profit?
It would be rare to use any exotic, expensive drug in routine orthopaedic surgery. Some of the anaesthetic agents are moderately expensive – it’s probably possible to spend a few £100 on inhaled agents and antiemetics if you really try. A typical joint replacement patient might get through £2 worth of Morphine, £0.50 worth of paracetamol and a few shots of antibiotics would cost £10. Most of the drugs we use have been around for decades and are well out of patent. There’s no reason for anybody to be recouping R&D costs from them.
People like rheumatologists get to prescribe the really pricey biological agents. I understand that the NHS has been criticised in the US for beating pharmaceutical companies down in price. I honestly don’t know whether private patients benefit from the availability of cheaper drugs in the UK, but they would be expected to pay the full cost of private prescriptions, at least for anything prescribed on a short term basis. But this isn’t relevant to the question of whether you can do a joint replacement for £8K and still turn an honest profit.
Who pays when things go wrong and have to be redone?
That’s a good question. Arguably it’s reasonable for the public sector to pick up the tab if someone has something done privately which they might also have had done by the public sector but with a longer wait. The unfairness comes when someone convinces a surgeon operating for profit to do something brave or frivolous, and the public sector gets to pick up the pieces.
Presumably in the USA these costs will have to be covered by the private sector and so included in the cost of any surgery, and I agree this is something that would push up the cost of private surgery in a direct comparison. Typically in the UK the private sector would just leave the high risk patients to the NHS so for joint replacement surgery these costs would be reasonably low.
If the US system charges patients differently for the same procedure based on their comorbidities then I would have thought it would still be reasonably fair to compare costs for younger fitter patients where the disasters with be rare. If the US system charges a flat rate then the costs of looking after the very elderly and frail will be driving up costs for the younger patients?
Who pays the benefits and retirement costs for the employees?
The private hospitals, so it will be included in the cost paid by the patient or their insurance. Nursing staff will typically work full time at a private hospital and so will need pension contributions etc from their employer. Surgeons or doctors will typically do private work on a self-employed basis and may choose whether they want to invest it or spend it as they see fit.
Who pays to treat foreigners who leave without paying?
Private hospitals would typically expect payment or proof of insurance in advance. If lots of people were leaving without paying then this would push prices up and not down.
johnh wrote:
Doctors are painful to deal with and work hard to avoid their patients. Every interaction I’ve had with a “normal” US doctor (e.g. in the top-rank Palo Alto Medical Foundation) has lasted less than one minute – their goal seems to be to avoid patients as much as possible. Luckily I had for a long time (but no longer, sniff) a French doctor here in the US, who did things very differently – 15 minute appointments and a deep interest in everything around the patient.If you do get involved with the system, they will spend $10K’s of your money doing pointless tests, partly to make money and partly because they are terrified of lawsuits.
Interestingly, that’s totally contrary to my personal experience. I found they take much more time than in Europe, patiently explain what’s going on and are extremely responsive to queries. I just recently had a little accident and subsequent surgery and my surgeon answers email questions within minutes (to my amazement) even on a Sunday. This is at Cedars-Sinai in L.A. Pretty much same experience with my primary care doc, who unfortunately has moved on (out of state).
Because of my rather unusual insurance situation I normally pay and get the fees reimbursed. The totally weird thing about that is that I get about an 80% (!!) discount on the ‘normal’ insurance-paid price. Madness, explained to me once buy a doc here as a factor of the insurance companies simply refusing to pay, so the hospitals have to mark up like crazy to get their money. The really crazy thing is that many procedures are actually cheaper here than in Europe, as long as you pay upfront.
I am certainly not defending this mad system, but there’s more to it than meets the eye.
If @johnh hadn’t said otherwise I’d assume from his story that he had Kaiser ‘insurance’ – this is a business/model in which the insurance also provides the doctors and facilities, at low monthly subscriber cost, and it provides all the attentive care you’d expect 
I’d like to see an invoice for a UK private hospital that has performed a joint replacement, all costs included and with privately educated staff and no facility subsidy of any kind, billed at £8K to an insurance company 
That said, cash prices for the extensive medical treatment of foreigners in the US are indeed a lot cheaper than the ‘sticker price’ when the provider must deal with insurance. That ‘sticker price’ is however not what the insurance company actually ends up paying, so the 80% discount thing is illusory.
I’d prefer to pay cash for any medical care under maybe $10K per year, as would a whole lot of other people. Unfortunately, the changes in US health care law a few years ago made this mostly illegal, now you are forced to buy insurance with a small deductible. The decades ago system in which you paid the provider directly and were reimbursed by insurance would be much preferable for me, and @172driver if that’s what you have you’re doing well!
Peter wrote:
Plenty of UK consultants make $300k, but from a conversation I had about 3 years ago you could probably get a couple of heart transplants done here for $500k
Do you mean on the NHS or privately, or a combination?
Usually in combination, though perhaps just one day a week on the NHS to show proper liberal credentials
FYI when I said $300K/year, it was for surgeons on staff at US hospitals, not the US equivalent of ‘consultants’. What they might make is their own business.
I’m sure the guy who did my mother’s surgery makes considerably more than $300K. He started life on a small Caribbean island and has apparently worked way up by virtue of surgical skill. I found his ego a bit overwhelming, but he did a very good job technically.
I’d assume from his story that he had Kaiser ‘insurance’
Now I have Medicare, which is horribly expensive (~$16K/year just for me) and doesn’t pay for anything. I shudder to think what would happen if I needed something major, I guess I’d go broke the same as everyone else does in the US.
Before that I had various companies – United was one that I recall – depending on my employer. Luckily I never needed them to pay for anything much so I can’t say how good or bad they were. But the system itself is what terrifies me.
Getting back to the topic – one reason why Covid has been worse in the US is without doubt the medical system. Between people who are uninsured, or who have minimal, high-deductible policies that don’t really cover anything, most people just dare not get medical attention until things get very serious.
Now I have Medicare, which is horribly expensive (~$16K/year just for me) and doesn’t pay for anything.
johnh wrote:
one reason why Covid has been worse in the US
Here’s some data. The fatality rate in the US (percentage of total population) as a whole is less than UK, Spain, Italy, France, Belgium, Holland and so on. A bit over half in general, and number 12 in the world. I think you are in California? The rate there is currently almost exactly the same as Germany, a fraction of any of those countries, although it hasn’t stopped yet and time will tell. This is in spite of e.g. Imperial County on the Mexican border being greatly affected by an outbreak spreading from the town in Mexico directly across the border, with people coming to the US for treatment.
BTW, why is Belgium so high in fatality rate and why have I never heard it discussed? Number 2 after San Marino.
Thanks but I know what the bill they send me every month says…
Usually in combination, though perhaps just one day a week on the NHS to show proper liberal credentials
I don’t believe that is usually allowed. The standard NHS contract requires hospital consultants to do a full time job in the NHS before they can take on private work. Some people leave the NHS entirely in which case they can do as they wish.
I have just walked out through the car park and the poshest car was a BMW sports car, undoubtedly nice but there is no row of Aston Martins here – perhaps there is in Brighton. Personally I earn about 50K. I don’t feel hard done by, but would prefer people not to assume we are all on 300K. They have a tendency to quote you 30 hours of labour for fixing alternators then say ‘What exactly did you say you do again?’ with a puzzled expression when you say you can’t afford it.
