It doesn't cost 3k to have an MD do stitches. That money's going somewhere else (Actual experts may or may not know where).

I ama surgeon in MA. I get less than $800 for a hernia repair. That includes all the face time with the patient, explaining everything, doing the procedure and taking care of him after. The hospital gets $8000 and lets me use a 'special' room for an hour and another 'special' place for a few hours for the patient to 'sleep off' the anaesthesia. The doctor who provides anaesthesia gets <200$ for every 15 minutes. The gases and his machines cost a multiple of that. Hospitals inflate their costs by running red budgets (basically up spending for everything so they can justify higher budgets). A urologist in my facility who does robot surgery gets $1500 to remove a prostate for cancer. The hospital bills $80,000 for the procedure. And cancer surgery is being permitted even though a few weeks' delay will make little difference in the outcome for most cases. The hospital, who rents me my office by the way, is not giving me any breaks on the rent even though my business is down 50% . Even comcast gave me a $100 rebate because my volume is down. Can you imagine hospitals as corporations worse than Comcast?

The concept of 'efficiency of scale' does not translate to service industries. The only efficiency that happens is efficiency of funneling more money to higher salaries of higher executives. Hospitals are driven by profit and their incentives do not align with the precepts that led to their formation.

Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it.

By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage.

If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure."

Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1]

We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them.

[1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.

can I say 'bullshit' here without being rude? Hospitals ONLY provide services they can profit from. They could have a doc in an office to do the stitching you refer to. And save a crap ton on overhead. By offering a 'luxury pathway' not only do they up their profit, they make everyone else who is trying to save money for the system look bad. Hospitals CHOOSE not to offer cost effective care because there is less profit in it. And then they hide behind Stark regulations - 'we cannot help private practitioners, sorry'.

The primary issues - root cause - of our systemic faults lie in approximately three places:

1. We are fractured. There is no "healthcare system." That's a singular noun. We have a marketplace: that means things like three top-tier specialty centers in walking distance of each other in some areas, and nothing at all in others. About 90% of our problems derive from this. As do a number of our strengths (if you're in Boston, you should never have to wait more than two weeks for a colonoscopy. Ever.)

1a. The healthcare "system" is not equivalent to hospitals. Hospitals are a single strain of profit-seeking enterprise (non-profit hospitals are the same shit.) People keep confusing the two, resulting in advocacy for policies that just concentrate power harder into the hands of a few, massive, corporations.

2. We are bipolar. A huge, huge proportion of our healthcare dollars flows from medicare. A large portion of our people are uninsured or underinsured. The result is that healthcare operations are built (generally) around Medicare's billing practices and needs - that's what you optimize on to stay afloat. This means when someone uninsured comes in, though, they're thrown into an operational flow for which they're barely an after-thought. Prices set as a negotiation point with private insurers are brought to bear against uninsured people - and they get nailed with ridiculous, unpredictable prices that have nothing to do with... almost anything. These people either need to be brought under the umbrella of contracted rates (Medicare For All), or I don't know what. You're not going to convince an organization with operating margins <2% to launch a massive operational restructuring to accommodate people that generate <<1% of its profits. And don't think there isn't legislative collusion in this - in places like CA, hospitals are obligated to go to collections for all patients. They used to say, fuck it, that guy was poor as fuck, write it off as uncollectible and deduct it as charity care. The state didn't want to lose the tax dollars the hospital didn't bother collecting, so now hospitals are required to send those indigent patients to collections, or else the hospital has to eat the entirety of the cost - not even a tax deduction to soften the hit. That adds up to a lot of dollars.

3. Unfunded Mandates. Every policy change pushed through our healthcare system is perceived as targeting "those wealthy doctors" (doctor != hospital != healthcare system). Most docs I know drive a Nissan Altima or a Camry - they're middle-class cogs buried under debt. But the stereotype makes a good excuse for pushing policy changes and then not allocating money to accomplishing them. Which means every policy change fractures the system further apart socioeconomically - you have wealthy-client practices that can afford to stop taking insurance, opt-out of Medicare, and thus avoid all these unfunded mandates... and then you have everyone else. Which puts basically everyone but hospitals out of business, because only hospitals have the capital and the scale to be able to meet the new requirements. You think FB likes privacy regs because it builds a moat? Hospitals don't just get moats, they basically get to buy up every small practice in the area at cost. Your local PCP is small and nimble enough to say "oh, you're uninsured? Fuck it, $40." It's the hospital that says, "Oh, we'll send you a bill later," and then ho boy, get ready. This also includes getting docs who are super-bought into the status quo: "We profited off charging you hundreds of thousands in tuition. We sold the idea that you'd be set afterwards, and could just be a good doctor. Turns out that while paying off your loans, you're just middle-middle-class, after having been impoverished into your 30s. And now, for the good of society, we'd like to cut your income by another 20%, while asking you to continue working like a madman. No, we will not offer you one penny of federal loan forgiveness, even though it is the federal government that is gutting your income. In fact, we won't even let you declare bankruptcy - that's cause for revoking your license." Yeah, docs are going to buck really hard against most changes in hc reimbursement. Even so, look at organizations like Doctors For America - a shit ton of docs still agitate for reform, for the good of their nation, if not the good of their own pocket. A related point is the "shortage" of docs: training positions in hospitals are funded by the federal government. Funding which barely crawls. "We have a doctor shortage!" "Will you open new training positions?" "No." "Then..." "No worries, we'll have nurses take some night classes, skip the entirety of actual residency training, and then we can call them doctors, too! We'll just confuse people by telling them they're going to see 'providers', and that way we can avoid paying doctors for doctoring."

There's a lot of other headline bullet points, but most issues in American healthcare boil down to an interaction of the above three.

edit: I should add, big picture, that healthcare isn't magically divorced from the rest of our social ills. As wealth inequality grows, bear in mind two things: (1) wealth correlates to health, and disease burden to correlates to poverty, (2) people can still vote themselves healthcare allocation (i.e., medicaid). The result is that increasingly more disease is concentrated among the increasingly impoverished, which means they're legislatively allocating themselves healthcare ... without the resources to pay for it. Whether or not you like or dislike any of the above, a lot of our issues with hc reimbursement are linked - directly or indirectly - to questions of wealth inequality. Adjusted for inflation, most docs have seen their real income stagnating, hard, for decades - and that's specifically as a result of trying to cheapen them, because they're increasingly paid for with redistributed tax dollars rather than anyone actually buying healthcare.

The healthcare system in the US isn't a marketplace either. For markets to function you have to know how much something will cost before you buy it, and you have to be able to make decisions based on cost. For most Americans, health pricing is a black box indirected by hospitals and insurance companies. And good luck getting an ambulance to take you to a cheaper hospital in an emergency.