Am I missing snarkasm? I used to work for a multi-doctor practice. We had our own pharmacy; one of my assignments was to figure out if it was profitable.

A quick glance suggests to me that the study only measures cost, not where the money goes. The three possibilities that jump to my mind are profit, waste, and subsidies to other forms of healthcare. The first one is the most likely to my mind, mainly cost in the form of rent to the artificially limited resource of doctors. Assuming the artificial limitation is fixed, deploying them here is a form of waste.

But I want to stick in a word about the third. My pet peeve about American healthcare is that it is not transparent. A lot of medical billing is inflated in the hope that it will pay for unprofitable sectors, particularly ER. This is a form of price discrimination, one of the largest examples I know. In theory, monopolistic price discrimination and competition both produce efficient outcomes. But I’d feel a lot safer with government interventions (subsidies, for example) in a price system than a monolithic system designed for non-transparency.

Second — if you break down the barrier between pharmacies and care providers — the next logical step is to allow physicians to have pharmacies — I think you can imagine the cost implications of that.

Third, conditions like UTIs — especially recurrent ones, in women who already have a regular physician — probably don’t even need a visit with anyone. The issue is that a brief phone call encounter is not re-reimbursable at all. (Generally people with multiply recurrent UTIs are given prescriptions for antibiotics, that they start on their own accord when sxs. start).

I have not heard about the Singapore system.

I guess that’s “systematic” and a “reason,” but I’d like evidence for it.

Does he know about the system in Singapore? It is a counterexample to the vast majority of sweeping claims that people make about healthcare, including the obvious interpretation of this statement. Singaporean healthcare is competitive, by most meanings of the word. I don’t know any demographically-adjusted numbers for it, but unadjusted, it appears much more cost-effective. Probably adjustment would make it merely comparable.