8 ms·

The $2.7 Trillion Medical Bill

56 points by nh 13y ago

w1ntermute 13y ago
One big problem with the current system for pharmaceutical products is that the drug companies make little to no margnial profit in non-US markets, due to the monopsonistic pressures of a single-payer system driving down prices as low as they can possibly go. This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market. Without the US market, there would be no incentive to actually create the drugs. In essence, Americans are subsidizing the socialized healthcare systems of other countries.
- weego 13y ago
  You clearly have no experience dealing with NHS purchasing.
  - Avshalom 13y ago
    If there's one thing governments are famous for it's their brutally low margin contracts with private industry. ... no wait.
    - jellicle 13y ago
      You can't argue it both ways - "government" can't be totally incompetent and overpay for everything, and also at the same time be driving such a hard bargain that the only place for drug companies to make a profit is in the U.S. At most one of those can be true (and possibly neither). Which do you pick to be true?
- DanBC 13y ago
  Do you have any citations for that?
- rhizome 13y ago
  Drug companies use Hollywood Accounting, though.
- danmaz74 13y ago
  So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? By the way, aren't there many people here that say it's the legal duty of the directors of a company to do everything they can to maximize shareholders' value? Wouldn't THAT (make less money than legally possible in the US) be a violation of that supposed duty?
  - w1ntermute 13y ago
    > So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? No, I didn't mean anything like that. I have no idea how you got that out of what I said. > By the way, aren't there many people here that say it's the legal duty of the directors of a company to do everything they can to maximize shareholders' value? Yes, and it is. > Wouldn't THAT (make less money than legally possible in the US) be a violation of that supposed duty? Yes, but it's not happening, so I don't see your point.
    - danmaz74 13y ago
      >> So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? >No, I didn't mean anything like that. I have no idea how you got that out of what I said. You wrote: "This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market" (emphasis mine). What did you mean with that phrase, if not that if they could make their real profits outside the US pharmaceutical companies wouldn't have to recoup their costs in the US?
  - MarkMc 13y ago
    > So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? You're right that a drug company will always charge as much as it can, so the US price of a drug will not be affected by the price it can charge elsewhere. However, the chance a drug is developed in the first place is dependant on the total size of the market for that drug. If the potential profit for, say, a breast cancer cure is $300 billion rather than $100 billion then there is more chance that a cure will be found.
- bosie 13y ago
  Pharma companies spend twice as much on marketing/advertising for a new drug than on its R&D [1,2]. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174966/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174966/ [2] Ben Goldacre. Bad Pharma. 2012. Fourth Estate
  - ams6110 13y ago
    Are you contending that if they did not market/advertise their new drugs they more easily recoup their R&D expenses?
    - robotresearcher 13y ago
      Why not? Doctors are actively interested in useful new things and seek them out. Do you have to "ask your doctor today about" the new chemotherapy?
    - venomsnake 13y ago
      No. Effective drugs don't need big marketing budgets. Why? Because they are effective. And health care is market is with fixed demand. If your drug is best in class everyone with this condition will take it. They will go with second third line of defense drugs only if the primary is not suitable in the case (side effects/other conditions). And if you want to boost the sales of your second line drug convincing people it is the best you are actively hurting the patients.
    - robbiep 13y ago
      In many other markets (Australia for example) it is illegal to advertise drugs to consumers. Doctors find out through journal articles etc- there is no need to market to us
- guelo 13y ago
  You've learned the pharmaceutical industry's PR talking points well.
- calibraxis 13y ago
  Unfortunately, this commonly-cited argument is propaganda. And pernicious: it appeals to nationalism, framing US citizens as noble suckers who somehow help the entire world by letting corporations rob them blind. (With scare-words like socialism, framing it in terms of economic patriotism. Evil countries unleashing efficient socialist negotiators against poor capitalist Big Pharma.) Public Citizen and many others have done research debunking such claims in detail. (http://www.nybooks.com/articles/archives/2004/jul/15/the-truth-about-the-drug-companies/?pagination=false http://www.nybooks.com/articles/archives/2004/jul/15/the-tru...)
- antr 13y ago
  Your entire statement is false/untrue and lacks intellectual rigour. Let me start by saying that half of my family works in the healthcare sector: my dad is trauma surgeon, my sister is a chemical engineer at a (very) large European pharma company, and my mum works extensively with pharma sales/marketing teams around Europe. I'm no expert, but I tangentially know the industry. i. 6 out of the top 10 pharma companies by revenues are European (Novartis, Roche, GSK, Sanofi, Bayer, Astra Zeneca). ii. Europe accounts for 1/3 of all pharma R&D in the world. So with the above two points in context, let me pull apart your unsubstantiated comment: First, lets talk about pharma and drugs for a second. >make little to no margnial profit in non-US markets European pharma co. Novartis made in 2012 revenues of $19.7bn in Europe vs $18.6bn in the US (and a total of $56.7bn). Novartis invested 21% of sales into R&D. U.S. pharma company Pfeizer, total revenues of $59bn in 2012, U.S. was $27bn and international $36bn. Pfeizer invested $7.9bn in R&D (c. 13% of revenues). Look at any other large US or European company and you will see that Europe is as profitable, if not more, than the U.S. Europe, by itself, on a total revenue minus total R&D expenditure, is (in the $ billions) profitable. >pressures of a single-payer system driving down prices as low as they can possibly go. No European country has a single-payer, that is false. Purchasing is not made by a country, and it is not even done at the regional level. Purchasing decisions are made at a hospital per hospital level. Each hospital manages its own budget and pretty much pay market rates (to check this simply go to the pharma companies annual reports and do the math). >This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market. So given the math above, and given that R&D is a fixed investment (even if the final compound is produced ad infinitum), the U.S. tends to contribute to 25% to 35% of any pharma companies' revenues, while the rest of the world makes up the rest. This simply means that the U.S. by itself would cover R&D, but in no way it could cover for R&D + operational costs. >Without the US market, there would be no incentive to actually create the drugs. European pharma, by itself, makes over 1/3 of all world R&D in pharma, while U.S. contributes 1/3 of all revenues. Without the rest of the world, U.S. companies would not invest at all. Second, lets talk ER and other primary patient care with no drugs involved. How is it that any transplant, operation, etc. in any part of the world is cheaper, face value wise, in RoW than in the US? Well, let me say that while in Europe healthcare is considered important, it is not seen as a business, but a basic right. Not the right to FREE healthcare, but the right to healthcare. Healthcare in EU countries is seen as the recurring cost of keeping the citizens healthy, and hence healthcare is managed as a cost centre and not a profit centre. E.g. Doctors and nurses, across the same EU country get paid very consistent salaries, unlike the US, where a surgeon in Orlando makes a completely different salary than one in Idaho, or even in the same city! Salaries of public employees in the EU are transparent and consistent. The overall U.S. healthcare system lacks price transparency at every level. How can it be that the same surgical procedure in the same U.S. city varies in price by 2x or 3x? In the U.S., hospitals, large healthcare companies and other parties are there to make a profit, not to run a business at a loss. They have shareholders, it's understandable. In Europe, the shareholder is the citizen, and healthcare is not a for-profit business. Nevertheless, if you want more "customer service" in your European healthcare you can have it, pay for private insurance, but pay for it, it's not illegal. My final comment would be this insightful chart: https://www.e-education.psu.edu/drupal6/files/geog438w/images/module5/LifeExpectancy.gif https://www.e-education.psu.edu/drupal6/files/geog438w/image...
- jaynos 13y ago
  If that were true, why bother selling abroad? Since they do sell abroad, it would seem to be a prudent business decision.
- rdtsc 13y ago
  Funny those are exactly the typical reasons circled through conservative and libertarian propaganda. As "when people tell you about the insane prices here is what you respond with...". Kind of like typical religious apologetics. "When people question your Bible beliefs here are points you use to refute their arguments..." stuff like that.
- netc 13y ago
  Let's say some policies are changed in EU and pharmaceutical companies make as much or more profit in EU as in US - do you think they will reduce the cost of drugs in US? Perhaps not - remember they have shareholders. They probably aren't going to say, "oh! we have made enough money on this drug. Let's reduce the price now.".
kunle 13y ago
Seeing that US patients pay 20x for Lipitor as New Zealand is a pretty troubling stat. Even though it's clearly optimized for shock value, paying $124/unit can mean a patient is choosing between solvency and health. Pretty sad.
- hga 13y ago
  Echoing the comment that w1ntermute's made after your's, Lipitor/atorvastatin wouldn't freaking exist as a drug without the system where it costs so much in the US during the period of patent protection. According to Wikipedia, it was first synthesized in 1985 and approved by the FDA in 1996; that period is well into the "you won't recover your drug development money without the US market" phase. But don't worry, if the usual suspects are successful, we'll all be paying peanuts for drugs in due course. Pity there will be no effective antibiotics against many resistant drug bacteria strains.... (The thing that really gets me is how many of these advocates for an end of medical innovation as an inevitable outcome of their nostrums will find their own lives cut short in due course due to it. Ideology trumps self-preservation.)
  - samstave 13y ago
    Seems like we need a nationalized method for finding drugs, a DARPA for pharma that spends some of the trillions from defense weaponry on defense of national health.
    - hga 13y ago
      Making the process even more political is going to improve it???
      - tstactplsignore 13y ago
        Radical American conservative propaganda aside ("The government can't do anything right!"), actually, creating a nationalized pharma research and development program is an interesting idea definitely worth considering. The public sector has shown itself to be very capable of scientific innovation (see NASA, NIH, NOAA, the Internet, the Manhattan project), and even if several tens of billions were invested in the program, it would probably even become a net positive for the government if discoveries are licensed and sold at highly reasonable prices, both giving the program direct income and reducing national healthcare spending. And, of course, the agency would be able to focus on drugs which aren't the "Take 10 pills for the rest of your life while we bill you" kind. At the very least, there needs to be better regulation of big pharma practices and prices in the US. Unfortunately, due to the lobbying power of the industry, I doubt we'd see any real solution anytime soon.
chasb 13y ago
Patients, doctors, and payers: Usually only one of these stakeholders knows what the cost of a treatment is. It's not hard to see how the incentives quickly become perverse, especially when a health system gets involved. I, for one, am hoping that Accountable Care Organizations will prove financially viable.
te_chris 13y ago
Reading these articles is always mind boggling as a non American. I just checked what my private health insurance costs me here in NZ: $390 a year. This plan includes 80% rebates for pretty much anything done privately, plus a number of other private elective procedures fully covered and reimbursements on minor stuff like Physio, gp visits etc. if I doubled this I'd get stuff fully covered and likely get optical and dental too. Obviously this is cheap because its just augmenting the public system, but I probably don't pay much more tax than you guys. The difference is just crazy to me.
- brazzy 13y ago
  > Obviously this is cheap because its just augmenting the public system I.e. it's not comparable at all without knowing how much the "public system" costs. A more comparable data point: my German "free" (public) health care costs almost €6000 per year, of which €3200 is paid by me and the rest by my employer. There are co-payments, but very low (a maximum of €10 for drugs and per day of hospital stays).
  - phaemon 13y ago
    Yours isn't comparable either since you pay that much because you're highly paid. If you earned less, you'd pay less. Also, the US has a "public system" too which you need to account for. It costs more (per-capita) than the UK's NHS costs.
    - brazzy 13y ago
      > Yours isn't comparable either since you pay that much because you're highly paid. And yet, it's cheap compared to plans in the USA, given that there is no such thing as a "deductible". And the premium doesn't rise with age, or any existing conditions.
    - digikata 13y ago
      And before you compare per-capita costs of the piecemeal US public system to those of the entire UK NHS system. The limited public system in the US is typically caring for a patient in a older demographic (medicare), and some portion of people on disability, and war vets (if you include the VA). All of which might be expected to carry a higher need for medical care then the entire UK demographic. Essentially, it pulls a higher cost slice of patients in the US off the private healthcare systems books - and even at that comparisons that I've looked at seem to point to the private system being some multiple of 50-300% more expensive than public health system.

56 points by nh 13y ago

One big problem with the current system for pharmaceutical products is that the drug companies make little to no margnial profit in non-US markets, due to the monopsonistic pressures of a single-payer system driving down prices as low as they can possibly go. This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market. Without the US market, there would be no incentive to actually create the drugs. In essence, Americans are subsidizing the socialized healthcare systems of other countries.

weego 13y ago
You clearly have no experience dealing with NHS purchasing.
- Avshalom 13y ago
  If there's one thing governments are famous for it's their brutally low margin contracts with private industry. ... no wait.
  - jellicle 13y ago
    You can't argue it both ways - "government" can't be totally incompetent and overpay for everything, and also at the same time be driving such a hard bargain that the only place for drug companies to make a profit is in the U.S. At most one of those can be true (and possibly neither). Which do you pick to be true?
DanBC 13y ago
Do you have any citations for that?
rhizome 13y ago
Drug companies use Hollywood Accounting, though.
danmaz74 13y ago
So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? By the way, aren't there many people here that say it's the legal duty of the directors of a company to do everything they can to maximize shareholders' value? Wouldn't THAT (make less money than legally possible in the US) be a violation of that supposed duty?
- w1ntermute 13y ago
  > So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? No, I didn't mean anything like that. I have no idea how you got that out of what I said. > By the way, aren't there many people here that say it's the legal duty of the directors of a company to do everything they can to maximize shareholders' value? Yes, and it is. > Wouldn't THAT (make less money than legally possible in the US) be a violation of that supposed duty? Yes, but it's not happening, so I don't see your point.
  - danmaz74 13y ago
    >> So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? >No, I didn't mean anything like that. I have no idea how you got that out of what I said. You wrote: "This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market" (emphasis mine). What did you mean with that phrase, if not that if they could make their real profits outside the US pharmaceutical companies wouldn't have to recoup their costs in the US?
- MarkMc 13y ago
  > So, you mean that if US drug companies made more money abroad, they would decide to make less money than they possibly can in the US? You're right that a drug company will always charge as much as it can, so the US price of a drug will not be affected by the price it can charge elsewhere. However, the chance a drug is developed in the first place is dependant on the total size of the market for that drug. If the potential profit for, say, a breast cancer cure is $300 billion rather than $100 billion then there is more chance that a cure will be found.
bosie 13y ago
Pharma companies spend twice as much on marketing/advertising for a new drug than on its R&D [1,2]. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174966/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174966/ [2] Ben Goldacre. Bad Pharma. 2012. Fourth Estate
- ams6110 13y ago
  Are you contending that if they did not market/advertise their new drugs they more easily recoup their R&D expenses?
  - robotresearcher 13y ago
    Why not? Doctors are actively interested in useful new things and seek them out. Do you have to "ask your doctor today about" the new chemotherapy?
  - venomsnake 13y ago
    No. Effective drugs don't need big marketing budgets. Why? Because they are effective. And health care is market is with fixed demand. If your drug is best in class everyone with this condition will take it. They will go with second third line of defense drugs only if the primary is not suitable in the case (side effects/other conditions). And if you want to boost the sales of your second line drug convincing people it is the best you are actively hurting the patients.
  - robbiep 13y ago
    In many other markets (Australia for example) it is illegal to advertise drugs to consumers. Doctors find out through journal articles etc- there is no need to market to us
guelo 13y ago
You've learned the pharmaceutical industry's PR talking points well.
calibraxis 13y ago
Unfortunately, this commonly-cited argument is propaganda. And pernicious: it appeals to nationalism, framing US citizens as noble suckers who somehow help the entire world by letting corporations rob them blind. (With scare-words like socialism, framing it in terms of economic patriotism. Evil countries unleashing efficient socialist negotiators against poor capitalist Big Pharma.) Public Citizen and many others have done research debunking such claims in detail. (http://www.nybooks.com/articles/archives/2004/jul/15/the-truth-about-the-drug-companies/?pagination=false http://www.nybooks.com/articles/archives/2004/jul/15/the-tru...)
antr 13y ago
Your entire statement is false/untrue and lacks intellectual rigour. Let me start by saying that half of my family works in the healthcare sector: my dad is trauma surgeon, my sister is a chemical engineer at a (very) large European pharma company, and my mum works extensively with pharma sales/marketing teams around Europe. I'm no expert, but I tangentially know the industry. i. 6 out of the top 10 pharma companies by revenues are European (Novartis, Roche, GSK, Sanofi, Bayer, Astra Zeneca). ii. Europe accounts for 1/3 of all pharma R&D in the world. So with the above two points in context, let me pull apart your unsubstantiated comment: First, lets talk about pharma and drugs for a second. >make little to no margnial profit in non-US markets European pharma co. Novartis made in 2012 revenues of $19.7bn in Europe vs $18.6bn in the US (and a total of $56.7bn). Novartis invested 21% of sales into R&D. U.S. pharma company Pfeizer, total revenues of $59bn in 2012, U.S. was $27bn and international $36bn. Pfeizer invested $7.9bn in R&D (c. 13% of revenues). Look at any other large US or European company and you will see that Europe is as profitable, if not more, than the U.S. Europe, by itself, on a total revenue minus total R&D expenditure, is (in the $ billions) profitable. >pressures of a single-payer system driving down prices as low as they can possibly go. No European country has a single-payer, that is false. Purchasing is not made by a country, and it is not even done at the regional level. Purchasing decisions are made at a hospital per hospital level. Each hospital manages its own budget and pretty much pay market rates (to check this simply go to the pharma companies annual reports and do the math). >This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market. So given the math above, and given that R&D is a fixed investment (even if the final compound is produced ad infinitum), the U.S. tends to contribute to 25% to 35% of any pharma companies' revenues, while the rest of the world makes up the rest. This simply means that the U.S. by itself would cover R&D, but in no way it could cover for R&D + operational costs. >Without the US market, there would be no incentive to actually create the drugs. European pharma, by itself, makes over 1/3 of all world R&D in pharma, while U.S. contributes 1/3 of all revenues. Without the rest of the world, U.S. companies would not invest at all. Second, lets talk ER and other primary patient care with no drugs involved. How is it that any transplant, operation, etc. in any part of the world is cheaper, face value wise, in RoW than in the US? Well, let me say that while in Europe healthcare is considered important, it is not seen as a business, but a basic right. Not the right to FREE healthcare, but the right to healthcare. Healthcare in EU countries is seen as the recurring cost of keeping the citizens healthy, and hence healthcare is managed as a cost centre and not a profit centre. E.g. Doctors and nurses, across the same EU country get paid very consistent salaries, unlike the US, where a surgeon in Orlando makes a completely different salary than one in Idaho, or even in the same city! Salaries of public employees in the EU are transparent and consistent. The overall U.S. healthcare system lacks price transparency at every level. How can it be that the same surgical procedure in the same U.S. city varies in price by 2x or 3x? In the U.S., hospitals, large healthcare companies and other parties are there to make a profit, not to run a business at a loss. They have shareholders, it's understandable. In Europe, the shareholder is the citizen, and healthcare is not a for-profit business. Nevertheless, if you want more "customer service" in your European healthcare you can have it, pay for private insurance, but pay for it, it's not illegal. My final comment would be this insightful chart: https://www.e-education.psu.edu/drupal6/files/geog438w/images/module5/LifeExpectancy.gif https://www.e-education.psu.edu/drupal6/files/geog438w/image...
jaynos 13y ago
If that were true, why bother selling abroad? Since they do sell abroad, it would seem to be a prudent business decision.
rdtsc 13y ago
Funny those are exactly the typical reasons circled through conservative and libertarian propaganda. As "when people tell you about the insane prices here is what you respond with...". Kind of like typical religious apologetics. "When people question your Bible beliefs here are points you use to refute their arguments..." stuff like that.
netc 13y ago
Let's say some policies are changed in EU and pharmaceutical companies make as much or more profit in EU as in US - do you think they will reduce the cost of drugs in US? Perhaps not - remember they have shareholders. They probably aren't going to say, "oh! we have made enough money on this drug. Let's reduce the price now.".

kunle 13y ago

Seeing that US patients pay 20x for Lipitor as New Zealand is a pretty troubling stat. Even though it's clearly optimized for shock value, paying $124/unit can mean a patient is choosing between solvency and health. Pretty sad.

hga 13y ago
Echoing the comment that w1ntermute's made after your's, Lipitor/atorvastatin wouldn't freaking exist as a drug without the system where it costs so much in the US during the period of patent protection. According to Wikipedia, it was first synthesized in 1985 and approved by the FDA in 1996; that period is well into the "you won't recover your drug development money without the US market" phase. But don't worry, if the usual suspects are successful, we'll all be paying peanuts for drugs in due course. Pity there will be no effective antibiotics against many resistant drug bacteria strains.... (The thing that really gets me is how many of these advocates for an end of medical innovation as an inevitable outcome of their nostrums will find their own lives cut short in due course due to it. Ideology trumps self-preservation.)
- samstave 13y ago
  Seems like we need a nationalized method for finding drugs, a DARPA for pharma that spends some of the trillions from defense weaponry on defense of national health.
  - hga 13y ago
    Making the process even more political is going to improve it???
    - tstactplsignore 13y ago
      Radical American conservative propaganda aside ("The government can't do anything right!"), actually, creating a nationalized pharma research and development program is an interesting idea definitely worth considering. The public sector has shown itself to be very capable of scientific innovation (see NASA, NIH, NOAA, the Internet, the Manhattan project), and even if several tens of billions were invested in the program, it would probably even become a net positive for the government if discoveries are licensed and sold at highly reasonable prices, both giving the program direct income and reducing national healthcare spending. And, of course, the agency would be able to focus on drugs which aren't the "Take 10 pills for the rest of your life while we bill you" kind. At the very least, there needs to be better regulation of big pharma practices and prices in the US. Unfortunately, due to the lobbying power of the industry, I doubt we'd see any real solution anytime soon.

chasb 13y ago

Patients, doctors, and payers: Usually only one of these stakeholders knows what the cost of a treatment is. It's not hard to see how the incentives quickly become perverse, especially when a health system gets involved. I, for one, am hoping that Accountable Care Organizations will prove financially viable.

te_chris 13y ago

Reading these articles is always mind boggling as a non American. I just checked what my private health insurance costs me here in NZ: $390 a year. This plan includes 80% rebates for pretty much anything done privately, plus a number of other private elective procedures fully covered and reimbursements on minor stuff like Physio, gp visits etc. if I doubled this I'd get stuff fully covered and likely get optical and dental too. Obviously this is cheap because its just augmenting the public system, but I probably don't pay much more tax than you guys. The difference is just crazy to me.

brazzy 13y ago
> Obviously this is cheap because its just augmenting the public system I.e. it's not comparable at all without knowing how much the "public system" costs. A more comparable data point: my German "free" (public) health care costs almost €6000 per year, of which €3200 is paid by me and the rest by my employer. There are co-payments, but very low (a maximum of €10 for drugs and per day of hospital stays).
- phaemon 13y ago
  Yours isn't comparable either since you pay that much because you're highly paid. If you earned less, you'd pay less. Also, the US has a "public system" too which you need to account for. It costs more (per-capita) than the UK's NHS costs.
  - brazzy 13y ago
    > Yours isn't comparable either since you pay that much because you're highly paid. And yet, it's cheap compared to plans in the USA, given that there is no such thing as a "deductible". And the premium doesn't rise with age, or any existing conditions.
  - digikata 13y ago
    And before you compare per-capita costs of the piecemeal US public system to those of the entire UK NHS system. The limited public system in the US is typically caring for a patient in a older demographic (medicare), and some portion of people on disability, and war vets (if you include the VA). All of which might be expected to carry a higher need for medical care then the entire UK demographic. Essentially, it pulls a higher cost slice of patients in the US off the private healthcare systems books - and even at that comparisons that I've looked at seem to point to the private system being some multiple of 50-300% more expensive than public health system.