Nothing is a black box on purpose
Where the numbers come from.
If we do not have a hospital’s machine-readable file, we guess in public. Sourced anchors, modeled recipes, and intelligent guesses are tagged so a shopper or a staffer can see the floor.
Sourced anchor
Commercial prices vs Medicare, by state
State commercial-to-Medicare multiples are modeled from RAND Hospital Price Transparency (Round 5 / follow-ons): commercial allowed amounts as a percent of Medicare. Arkansas sits near the bottom (~164%); coastal flagships often exceed 300%. We apply that multiple to a Medicare-like unit price, then a hospital-type factor. This is not a named hospital’s contract extract.
Source: RAND Hospital Price Transparency studies; ACHI/state briefs for AR
Modeled from anchors
Hospital wage index
Labor and facility minutes scale with a CMS IPPS-style wage index (illustrative state averages, not the official FY table for every CBSA). Implants and drugs do not get the wage bump — they move on GPO/list prices.
Source: CMS IPPS wage index concept; state-average model
Sourced anchor
Maryland all-payer exception
Maryland’s HSCRC all-payer hospital rate setting compresses the commercial vs Medicare gap versus other states. We keep Maryland’s commercial multiple much closer to Medicare on purpose — a live US proof that prices can be posted and regulated without a 3× coastal markup.
Source: Maryland HSCRC; Commonwealth Fund all-payer summaries
Modeled from anchors
Saline bag acquisition vs bill
A 1L 0.9% NaCl bag is a commodity: hospital GPO acquisition is typically about $1–$3 (we use $1.80). Patient-facing bills of $40–$120 are the markup, not the fluid. Same pattern for gloves, tubing, and many generics.
Source: Public GPO/WAC ranges; hospital chargemaster examples in journalism (NYT, Kaiser Health News)
Modeled from anchors
Knee / hip implant cost
Primary TKA implant sets commonly cost hospitals ~$3k–$6k on GPO (we use $4,200). Patient/insurer prices of $20k–$45k are mostly OR time, markup, and market power — not titanium alchemy.
Source: Orthopedic implant pricing literature; CMS procedure files; GPO ranges
Sourced anchor
Cash menus beat insured allowed amounts — when they exist
Where a real prompt-pay cash menu exists (ASCs, some hospitals, Surgery Center of Oklahoma–style posting), cash is often below commercial allowed. The trap is the opposite list: chargemaster / uninsured ‘rack rate,’ which can exceed commercial. This site’s Shop floor is the prompt-pay menu. Backend also shows the rack rate so you can see the shakedown.
Source: Hospital price transparency MRFs; Surgery Center of Oklahoma public menu; Kaiser Family Foundation / Peterson-Kaiser Family Foundation cash vs negotiated analyses
Intelligent guess
Quality scores
State quality (0–100) is a modeled blend of typical CMS Overall Hospital Quality Star averages, outcomes, and access — not a CMS download for a named facility. Hospital archetypes then bump academic (+), community (base), and ASC (high for surgery, not applicable for births/chemo). Use it to sort, not to pick a real surgeon.
Source: CMS Care Compare star methodology (concept); state-average model
Modeled from anchors
Breast cancer chemo course
Default episode is eight outpatient infusion days of a generic adjuvant backbone (AC-T–like), HER2-negative. Drug acquisition is a blended basket (~$2,100/day hospital cost). HER2-targeted biologics or immunotherapy can 5–15× the drug line. We show that as a labeled add-on, not a surprise.
Source: NCCN-style regimen structure; ASP/WAC public ranges for generics vs biologics; hospital outpatient APC infusion packaging
Sourced anchor
Self-funded employer math
Most mid/large US employers are already self-funded (stop-loss + TPA/ASO). Premiums are not ‘insurance product cost’ — they are claims plus admin plus stop-loss plus PBM spread. Direct contracts and posted-price ASCs cut the claims layer; they do not require a new federal program.
Source: Kaiser Family Foundation Employer Health Benefits Survey; DOL self-funding share; NAIC stop-loss
Sourced anchor
Employer stop-loss premiums by attachment
2025 Aegis Risk Medical Stop-Loss Premium Survey: 1,268 plan sponsors, 1.2 million employees, $1.2 billion of stop-loss premium. Average specific (per-person) stop-loss, normalized to a paid contract, per employee per month: $229.40 at a $100,000 attachment; $120.01 at $200,000; $50.98 at $500,000; $17.69 at $1,000,000. That premium pays only after one person’s plan-paid claims in the year pass the attachment. It is not a health plan for the worker, not a $100,000 deductible on Healthcare.gov, and not a voucher for that much care. Affordable Care Act out-of-pocket maximums still cap the worker’s in-network year (about $9,200 self-only in 2025, $10,600 in 2026). Renewals 2025 about 8.8–10.1%. Almost nobody in the survey is on reference-based pricing or direct cash contracts.
Source: Aegis Risk / International Foundation of Employee Benefit Plans, 2025 Medical Stop-Loss Premium Survey; CMS / HHS out-of-pocket maximums for 2025–2026
Sourced anchor
Affordable Care Act definition of a health care sharing ministry
26 U.S.C. § 5000A(d)(2)(B): a health care sharing ministry is a 501(c)(3); members share a common set of ethical or religious beliefs and share medical expenses in accordance with those beliefs without regard to state of residence; members retain membership after developing a medical condition; the organization or a predecessor has been in existence at all times since December 31, 1999, and has shared members’ medical expenses continuously since then; annual audit. That definition is the federal individual-mandate exemption box (the penalty is $0 federally now). It does not automatically exempt an organization from state insurance codes. Washington RCW 48.43.009 copies the same seasoning test. A 2018 or 2022 “ministry” is not in the box.
Source: 26 U.S.C. § 5000A(d)(2)(B); RCW 48.43.009; HHS letters to ministries note that federal recognition does not supersede state insurance law
Sourced anchor
Samaritan Classic monthly shares vs a family job sticker
Samaritan Classic share chart effective August 1, 2025: one person $199–$365/month by age band; two person $620–$715; three-to-seven person $699–$715; eight-plus $865. Initial unshareable amount $1,000 per need; maximum shareable about $250,000 per non-maternity need unless Save to Share. Not a legal promise to pay. A typical family employer-plus-worker job-plan sticker remains in the mid-twenty-thousands (Kaiser Family Foundation Employer Health Benefits Survey neighborhood). Classic is after-tax from the household; the job sticker is mostly pre-tax employer spend plus a worker slice. Do not treat Classic as a health-savings-account-eligible high-deductible health plan. Monthly shares are generally not Internal Revenue Code §213 deductions or qualified health savings account distributions under current practice; 2020 proposed Internal Revenue Service regulations and later bills (e.g. H.R. 2062) would treat ministry membership more like medical insurance — not assumed enacted for 2026 payroll.
Source: Samaritan Ministries Classic membership share chart (effective Aug 1, 2025, as published in member/review tables); Samaritan Guidelines 2025; Kaiser Family Foundation Employer Health Benefits Survey (family premium neighborhood); IRS Pub. 969 / §213 practice on sharing memberships
Sourced anchor
New ministries and the duck: Washington, Zion, ClearShare
Washington Insurance Commissioner: ClearShare Health (incorporated 2022, marketed as a ministry) fined and ordered to stop unauthorized insurance for failing the 1999 continuous-sharing test. Unite Health Share Ministries: cease-and-desist after a consumer reported ~$5,000 shared on a need with ~$200,000 remaining; 2025 final order that they did not meet the ministry criteria. February 5, 2026: Washington Court of Appeals (Zion HealthShare, Inc. v. Office of the Insurance Commissioner, No. 40454-4-III) held Zion is an insurer and the 1999 seasoning in RCW 48.43.009 stands — new organizations must follow generally applicable insurance law. Colorado HB22-1269: sharing arrangements must report to the Division of Insurance. These actions freeze copies. They do not delete 1999 Samaritan. Commonwealth Fund 2018: ministries pull healthier people from the Affordable Care Act individual pool.
Source: Washington OIC news releases 2025 (ClearShare, Unite Health Share); Zion HealthShare, Inc. v. Office of Ins. Comm’r, Wash. Ct. App. Div. III, No. 40454-4-III (Feb. 5, 2026); Colo. C.R.S. 10-16-107.4; Commonwealth Fund, Health Care Sharing Ministries (2018)
Modeled from anchors
Admin theater
US whole-system admins per physician are commonly cited near ~10 vs ~2–3 in simpler-payer countries (Himmelstein hospital admin shares; BLS occupational mix). This site treats claims/prior-auth overhead as a real cost that cash posted-price care can skip — not as clinical quality.
Source: Himmelstein et al. hospital administration; BLS; Commonwealth Fund Mirror, Mirror
Modeled from anchors
Medicaid / Medicare / insured next to SCO cash
SCO does not post Medicaid, Medicare, or commercial rates. We model an all-in comparison so the columns are fair: Medicare ≈ 88% of the SCO cash bundle (typical OPPS + surgeon + anesthesia neighborhood), Medicaid ≈ 78% of that Medicare, insured ≈ Oklahoma commercial × Medicare (RAND-style ~2.05×). The point is the spread — cash vs the insured hospital path — not a named insurer contract.
Source: CMS OPPS/PFS concept; RAND commercial-to-Medicare for Oklahoma; SCO menu as cash anchor
Sourced anchor
SCO quality marker
SCO has published a 0.00% surgical infection rate (2021) vs a ~2.6% national average they cite. We score the center 88/100 as a high-quality cash ASC archetype — not a CMS star extract for a different facility.
Source: Surgery Center of Oklahoma public quality claims; CDC/national SSI ballpark they compare against
Modeled from anchors
340B / outpatient oncology spread
Eligible hospitals buy many oncolytics and supportive biologics at 340B ceiling prices, then bill commercial plans near ASP-plus (or higher). The spread on Keytruda-class, pegfilgrastim, and trastuzumab is the cancer floor’s profit — not the infusion chair itself. Our buy vs billed numbers are illustrative blends, not a named 340B covered-entity invoice.
Source: HRSA 340B statute/guidance; MedPAC 340B reports; ASP public files; hospital outpatient chemo journalism
Modeled from anchors
Imaging contribution margin
Once the magnet or CT is installed, incremental scans are mostly tech time + contrast + read. Hospital outpatient posted/cash menus for MRI/CT/PET are typically several times a free-standing imaging center. We model hospital cash and apply the same Medicaid/Medicare/insured stack as surgery so floors are comparable.
Source: Hospital price-transparency MRFs; free-standing imaging cash menus; CMS OPPS imaging APCs (concept)
Modeled from anchors
Emergency facility levels
ED facility fees (levels 1–5) plus trauma activation are chargemaster theater: you did not shop, so list vs negotiated is the whole model. Our cash column is a prompt-pay-ish hospital outpatient analog; insured is Oklahoma commercial × Medicare. Not a named ED’s CDM extract.
Source: Hospital chargemaster / price-transparency facility-fee lines; ACEP facility-level coding concept
Modeled from anchors
Inpatient bed-day vs ICU day
Ward, PCU, and ICU SKUs are modeled hospital billed amounts for a facility day — not a named CDM. Med-surg cash ~$1,850–$2,650, step-down ~$2,800–$4,100, ICU ~$6,500–$8,200 (vent/ECMO higher). Same Medicaid/Medicare/insured stack as the rest of the directory so floors compare.
Source: CMS IPPS / MS-DRG facility concept; hospital price-transparency room-and-board lines; American Hospital Association hospital cost reports (concept)
Sourced anchor
Employer premium split and deductibles
Kaiser Family Foundation Employer Health Benefits Survey 2025: average family premium $26,993 (worker $6,850 / 26%, employer $20,143); single $9,325 (worker $1,440). Average general annual deductible for single coverage $1,886. HSA-qualified HDHP deductibles: $2,578 single / $4,932 family aggregate. HDHP with HRA family aggregate $6,912. A $10,000 family deductible is a steep design, not the average.
Source: Kaiser Family Foundation Employer Health Benefits Survey 2025; IRS Rev. Proc. 2025-19 (2026 HSA/HDHP)
Sourced anchor
Medicare 2026 Part A/B patient costs
CY 2026: Part B standard premium $202.90/month; Part B deductible $283 then 20%; Part A inpatient deductible $1,736 per benefit period. Most people pay $0 Part A premium. Original Medicare has no annual out-of-pocket maximum unless Medigap or Advantage is layered on.
Source: CMS 2026 Medicare Parts A & B Premiums and Deductibles fact sheet; MM14279
Sourced anchor
What the system spends per person in a year
NHEA 2024: $15,474 per US resident. Employer-sponsored insurance spent $8,000 per enrollee; all private insurance $7,676; Medicare $16,779; Medicaid $11,050. That is benefit spending, not the premium sticker. CMS personal health care by age is 2020 (child 0–18 $4,217, working-age 19–64 $9,154, 65+ $22,356). We scale those to 2024 dollars by the NHE per-capita ratio $15,474 / $12,637, so a family of four (two working-age, two children) is about $32,700 of care — the mean for that age mix, all payers, not this family’s claims file.
Source: CMS NHE Fact Sheet 2024; CMS Personal Health Care Spending by Age and Sex 2020; CHCF National Health Spending 2026 edition (ESI $8,000); Hartman et al., Health Affairs 2026 (NHE per capita $12,637 in 2020, $15,474 in 2024)
Sourced anchor
Where a private-insurance premium dollar goes
CMS NHEA 2023: private health insurance spent $1,464.6 billion. CHCF National Health Spending Almanac 2025 (PHI column): hospital care 38%, physician and clinical services 26%, retail prescription drugs 12%, net cost of health insurance 10%, dental 5%, other professional 3%, nursing 1%, home health 1%, other health care 1%, DME 1%. The pie on The 5% lists dental separately and folds the rest of those small lines into “everything else” (9%). Health Affairs (NHE 2023): net cost of private health insurance was 10.3% of PHI — admin, taxes, fees, underwriting gain or loss. Hospital in NHEA is the building (inpatient plus hospital outpatient/ER), not MEPS inpatient-only. Kaiser Family Foundation: 2025 large-group fully insured simple loss ratio about 91% (keep ~9%), in the same neighborhood; ACA MLR does not apply to self-funded plans, which cover about two-thirds of workers.
Source: CHCF National Health Spending Almanac 2025 (CMS NHEA 2023, spending by category and source of funds); Hartman et al., National Health Expenditures In 2023, Health Affairs; Kaiser Family Foundation, Medical Loss Ratio Rebates (2025 simple loss ratios)
Sourced anchor
Most people use little care in a given year
MEPS 2023 (Peterson-Kaiser Family Foundation): the bottom 50% averaged $433 of spending and accounted for 3% of the total; about 14% had $0; the top 5% averaged $72,918 and accounted for nearly half of all spending; the top 1% averaged $150,467. The 100-person room on The 5% takes “nearly half” as 50%, so the implied overall mean is $7,292 (5 × $72,918 / 0.50). That identity is the point: 10× the mean × 5 people = 50% of the pile. Within-band shape is modeled. Premium comparison uses Kaiser Family Foundation 2025 single $9,325 × 100 — a different year, not a 2023 premium file — so the top 5 take ~50% of spending and ~39% of stickers. MEPS 2022 overall mean was $6,765 (AHRQ Statistical Brief 560); that year the top 5% held 49.7% (cut $30,206; mean $67,321) and the bottom 50% held 2.8%. MEPS is the civilian noninstitutionalized population and runs below NHEA — it misses nursing homes and some spending. The mean is not a typical year.
Source: Peterson-Kaiser Family Foundation Health System Tracker, How do health expenditures vary across the population? (MEPS 2023); AHRQ MEPS Statistical Brief 560 (2018–2022)
Sourced anchor
Median dollars the plan actually paid, by insurer
MEPS 2021, insured adults: the median amount paid by the insurer (not the person’s total bill) was $1,369 for private insurance, $1,648 for Medicaid, and $3,643 for Medicare (IQR $456–$4,078, $389–$7,126, and $1,321–$10,519). That is the middle person in each program, not the mean. Household figures on Invested premiums multiply the adult median by covered lives — kids are modeled at the adult median. Lifetime pay-in vs pay-out inflates that same stacked median (and the Kaiser Family Foundation / tax stickers) at 4% for the years on each clock: job 26/30–64, Medicare claims 65–85, Medicaid tax the whole horizon. Typical Medicaid has $0 premium. This modeled household is not enrolled in Medicaid (job plan, then Medicare; not dual-eligible). NHEA 2024 means are much higher ($8,000 employer coverage, $11,050 Medicaid, $16,779 Medicare) because the sick tail pulls them up. AHRQ Statistical Brief 560: the 50th percentile of all people in 2022 was $1,361 of total spending.
Source: Mohan G, Gaskin D. Social Determinants of Health and US Health Care Expenditures by Insurer. JAMA Netw Open. 2024;7(10):e2440467 (MEPS 2021); AHRQ MEPS Statistical Brief 560 (2022 median cut $1,361); CMS NHEA 2024 per-enrollee means
Sourced anchor
What the top 5% actually buy
MEPS 2022 (AHRQ Statistical Brief 560): among people in the top 5% of expenses, dollars went to ambulatory events 32.5%, inpatient stays 27.9%, prescribed medicines 27.8%, home health 7.4%, dental/other 4.3%. The bottom 50% had essentially no inpatient (0.1%) or home health (0.1%). Adults in the top 5% : 75.1% had two or more AHRQ priority conditions vs 22.9% in the bottom 50%. Age 65+ is 40.5% of the top 5% vs 18.1% of the population. Private insurance 44.4% and Medicare 30.8% paid most of the top 5% bill; out-of-pocket 8.0%. Most common treated conditions in the top 5% (not the costliest): hypertension 42.9%, hyperlipidemia 35.6%, musculoskeletal/back 30.6%, diabetes 25.6%. About one-third of the top 5% are still there the next year (33.7% in 2012–13, Statistical Brief 481).
Source: AHRQ MEPS Statistical Brief 560 (Hernandez-Viver and Mitchell, March 2025); AHRQ MEPS Statistical Brief 481 (concentration and persistence, 2012–2013)
Sourced anchor
Most expensive hospital conditions
HCUP 2022: $548.5 billion of hospital production costs across 32.9 million stays. Septicemia was $60.0 billion (10.9% of costs, 2.42 million stays / 7.4% of stays, about $24,800 per stay) — #1 for Medicare, Medicaid, private, and uninsured. Volume is the lever: newborns had more stays (3.49 million) at ~$5,600 each ($19.6 billion); heart attack was more expensive per stay (~$28,100) but only 582,000 stays ($16.3 billion); spine ~$31,300 × 447,000 stays ($14.0 billion). Septicemia is a principal-diagnosis bucket for the crash (infection that went body-wide), not a shoppable elective. These are hospital costs via cost-to-charge ratios — not commercial allowed amounts, and they omit separately billed physician fees. AHRQ’s sepsis report (separate, broader definition) found stays up ~40% from 2016–2021 and costs $31.2 billion → $52.1 billion; some of that is COVID, aging, and coding. Osteoarthritis inpatient cost $5.6 billion; hip fracture $7.7 billion.
Source: AHRQ HCUP Statistical Brief 316, National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2022 (Liang, February 2026); AHRQ Report to Congress, An Assessment of Sepsis in the United States and its Burden on Hospital Care (2016–2021 trend, broader sepsis definition)
Sourced anchor
Biggest condition bills in the whole system
Dieleman et al. (JAMA 2025) on 2019 spending: more was spent on type 2 diabetes ($143.9 billion) than on any other of 148 conditions, then other musculoskeletal disorders ($108.6 billion), oral disorders ($93 billion), and ischemic heart disease ($80.7 billion). This is the whole population, not the top 5% slice. Cancers are split across many codes so they do not appear as a single #1 line. 40.5% of this spending was on people 65+.
Source: Dieleman JL et al. Tracking US Health Care Spending by Health Condition and County. JAMA. 2025. doi:10.1001/jama.2024.26790 (2019 estimates)
Sourced anchor
Specialty drugs are most of the drug bill
IQVIA Institute: specialty medicines account for about 54% of US medicine spending (up from 49% in 2018), driven by immunology and oncology. Median annual treatment cost for medicines launched in 2023 exceeded $150,000; oncology and rare-disease launches approached $300,000 per patient. This is why prescription drugs are 27.8% of the top 5% MEPS bill even though generic blood-pressure pills are cheap.
Source: IQVIA Institute, The Use of Medicines in the U.S. 2024 / outlook to 2028; IQVIA newsroom and Managed Healthcare Executive summaries of that report
Sourced anchor
Median family retirement accounts
Federal Reserve Survey of Consumer Finances 2022: 54.3% of U.S. families held retirement accounts (IRAs, Keogh, 401(k)/403(b)/TSP). Among families with those accounts, the median balance was $86,900 and the mean was $334,000 (2022 dollars). This is not all families — the other 45.7% are at $0 in these accounts. It also excludes Social Security and defined-benefit pensions.
Source: Board of Governors of the Federal Reserve System, Changes in U.S. Family Finances from 2019 to 2022: Evidence from the Survey of Consumer Finances (October 2023)
Sourced anchor
OECD health spending per person
OECD Health at a Glance 2025 (2024, USD PPP): United States $14,885; Switzerland $9,963; Norway $9,393; Germany $9,365; Netherlands $8,436; Austria $8,401; Sweden $7,871; Australia $7,469; France $7,367; Canada $7,301; Japan $5,790 (near the OECD average of about $5,967). The 5% page tabs are the ten highest-spending large systems plus Japan — the sourced high-night, low-price counterexample — plus Singapore. Luxembourg and Ireland sit nearby on the table; we skip them because commuters and GDP distortions make a bad peer. China is an OECD partner, not on this 2024 member per-capita stick, and is not in RAND’s 33-country drug indexes, iFHP private-plan hospital prices, or Wammes’s seven-country 5% shares — we do not mix a WHO PPP figure onto this identity. Singapore is also not OECD/RAND/iFHP/Wammes, but MOH posts typical public-hospital bills, so the tab is on the board with a labeled WHO GHED 2023 PPP per-capita ($6,551), not the 2024 OECD stick. A modeled top-5% year is per-capita × (share / 0.05). A 50% share is 10× the mean — the same identity as US MEPS. Japan’s 41% share is sourced (Wammes), so the implied year is 8.2× per-capita. This OECD stick includes nursing homes and admin, so the US implied year (~$148,850) is larger than MEPS 2023 ($72,918). Use the OECD stick to compare OECD countries; keep MEPS for the US household-survey close-up.
Source: OECD Health at a Glance 2025, Figure 7.4 / OECD Health Statistics 2025 (US country note $14,885; OECD average $5,967)
Sourced anchor
Every rich country has a 5% — the bill is not the same
Wammes / Tanke et al., PLOS ONE 2019: top 5% share of medical spending ranged from 41% (Japan) to 60% (Canada) across seven countries; the top 1% drove most of that spread (15% Japan to 33% Canada). High-cost patients look alike — older, more often female, several chronic conditions (circulatory, neoplasms, musculoskeletal). Utilization does not: Japan’s top 5% averaged 97.7 inpatient nights vs 6.6 in the US. Cost per inpatient night (PPP USD, ~2012–15): Japan $432 vs United States $3,180. Paper used MEPS for the US (community, undercounts institutions). Do not mix those older top-5% dollar means with OECD 2024 per-capita. The 5% page uses the shares and the night prices; the dollar comparison across tabs is OECD × share.
Source: Wammes JJG, Tanke M, et al. A challenge to all. A primer on inter-country differences of high-need, high-cost patients. PLOS ONE 2019;14(6):e0217353. Table 1 and Figs 2–4.
Sourced anchor
Peers are cheaper because of prices, not because they lack a 5%
Papanicolas, Woskie, Jha, JAMA 2018: the US does not use more of most services than other high-income countries; it pays higher prices, higher wages, more for technology, and more administration. Anderson, Reinhardt, Hussey, Petrosyan, Health Affairs 2003: “It’s the prices, stupid.” Concentration of spending on a small share of people is a high-income-country feature (see Wammes; US MEPS ~50% on the top 5%), not a US-only sickness pattern. Country tabs on The 5% spell the price lever: fee schedules, hospital budgets, national drug bargaining — not “they don’t have sepsis.” Wages (PPP): US generalists $218,173 vs $86,607 (Sweden) to $154,126 (Germany); specialists $316,000 vs $98,452 (Sweden) to $202,291 (Australia); nurses $74,160 vs $42,492 (France). Admin 8% of US spending vs 1–3% in the other 10. Pharma per capita $1,443 vs mean $749 (Switzerland $939). Life expectancy 78.8 vs 80.7–83.9; infant mortality 5.8 vs 3.6; 30-day stroke mortality actually better in the US (4.2 vs 7.9). Specialist wait ≥2 months: US 6%, France 4%, Germany 3%, Canada 39%. MRI 2013: US $1,145 vs Australia $350, Netherlands $461. CT: US $896 vs Canada $97.
Source: Papanicolas I, Woskie LR, Jha AK. Health Care Spending in the United States and Other High-Income Countries. JAMA. 2018;319(10):1024–1039. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid: why the United States is so different from other countries. Health Aff (Millwood). 2003;22(3):89–105.
Sourced anchor
US brand drugs are 4× other OECD countries
RAND / ASPE, 2022 IQVIA MIDAS manufacturer prices: US all-drugs 278% of 33 OECD countries combined (other countries pay 36¢ on the US dollar). Brand-name originators 422%. Unbranded generics go the other way — US 67% of other-country prices — and are 90% of US prescription volume, not of the top 5% bill. Bilateral all-drug indexes (US as % of that country): France 326, Australia 370, Netherlands 333, Sweden 333, Germany 294, Austria 276, Norway 248, Canada 229, Switzerland 219, Japan 347 (brands 464). France and Japan generally have the lowest prices among G7 comparison countries. The 5% page uses the brand-originator invert for drug lines (France ~22¢, Australia ~20¢, Canada ~31¢, Switzerland ~29¢, Japan ~22¢). Gross prices, not confidential rebates; even after a US rebate haircut, brands stay more than 3×. Japan’s presentation overlap with the US is the smallest in G7 (17% of Japanese volume); RAND’s active-ingredient robustness check still found Japan cheap.
Source: Mulcahy AW, Schwam D, Lovejoy SL. International Prescription Drug Price Comparisons: Estimates Using 2022 Data. RAND RR-A788-3 / ASPE, February 2024. Table B.1.
Sourced anchor
Same surgery, US private price is the outlier
iFHP / HCCI International Healthcare Cost Comparison Report 2024 (2022 private-plan medians): coronary bypass US $89,094 vs Australia $17,741 and Spain $10,734; hip replacement US $29,006 vs Australia $14,986; knee US $26,340 vs Australia $13,609; PCI US $34,504 vs Australia $10,230. Peterson-Kaiser Family Foundation: US hospital discharges per capita are below the peer mean; inpatient hips and knees are not higher. Commercial MRI is ~3× Medicare while Medicare sits near peer public fees. Country-tab hospital indexes for countries without an iFHP row are modeled from this neighborhood, not a second claims extract — except Japan, whose hospital index is the sourced Wammes night ($432 / $3,180), not an iFHP private-plan CABG (iFHP does not publish Japan), and Singapore, whose hospital invoices are MOH public B2 typical bills (see moh-sg-bills-2023).
Source: International Federation of Health Plans and Health Care Cost Institute, International Healthcare Cost Comparison Report 2024. Peterson-Kaiser Family Foundation Health System Tracker, How do healthcare prices and utilization in the United States compare to peer nations?
Sourced anchor
Singapore posts the typical hospital bill
Singapore Ministry of Health, typical transacted bills for Singapore citizens, 1 Jan–31 Dec 2023, inclusive of GST, after government subsidy if applicable, before MediShield Life / Integrated Shield / MediSave. Public Ward B2 medians: CABG + valve (SD813H) S$16,381; primary hip replacement (SB839H) S$8,871; unilateral primary knee (SB810K) S$7,395. Converted at 1.34 SGD per USD (2023 average) for the 5% page dollar comparison with iFHP US private-plan medians (CABG $89,094, hip $29,006, knee $26,340). Private inpatient knee typical S$43,138 — private Singapore can match US commercial; the public B2 floor is the system. Per-capita on that tab is WHO GHED / World Bank SH.XPD.CHEX.PP.CD 2023: $6,551 PPP, not OECD Health at a Glance 2024. Drug ¢ is modeled (ACE + GPO); Singapore is not in RAND’s 33 OECD indexes.
Source: Singapore Ministry of Health, Hospital Bills and Fee Benchmarks (TOSP SD813H, SB839H, SB810K), transacted 2023. World Bank indicator SH.XPD.CHEX.PP.CD (WHO Global Health Expenditure Database), Singapore 2023 = 6,551.
Sourced anchor
Federal health programs vs the deficit and the debt path
CBO, The Budget and Economic Outlook: 2026 to 2036 (February 2026). FY2026: outlays $7.4 trillion (23.3% of GDP), revenues $5.6 trillion (17.5%), deficit $1.9 trillion (5.8%). Major health care programs — Medicare net of premiums, Medicaid, CHIP, and Affordable Care Act marketplace subsidies — $1,908 billion (6.0% of GDP). Medicare net $1,063 billion; Medicaid/CHIP/marketplace $845 billion. Social Security $1,666 billion. Net interest $1,039 billion. Defense $885 billion. Debt held by the public $30.2 trillion at end of FY2025, 101% of GDP in 2026, 120% in 2036. Social Security plus Medicare 8.7% of GDP in 2027 to 10.1% in 2036. CBO: aging, plus federal health cost per beneficiary growing faster than GDP per capita. Committee for a Responsible Federal Budget (February 12, 2026) on those tables: of nominal outlay growth 2026–2036, major health 30%, net interest 28%, Social Security 27%, mandatory veterans 5%, everything else 10%. The 2026 coincidence that major health ≈ the deficit is arithmetic on that baseline, not a CBO slogan.
Source: Congressional Budget Office, The Budget and Economic Outlook: 2026 to 2036 (February 2026), including Table 1 / major health care programs footnote. CRFB, ‘90% of Spending Growth Will Come From Health, Retirement, Veterans, & Interest’ (February 12, 2026).
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Certificate-of-need is the competitor’s veto
National Conference of State Legislatures (January 2024): 35 states and the District of Columbia still run some certificate-of-need. American Action Forum’s restrictiveness map lists no certificate-of-need or equivalent in California, Colorado, Idaho, Kansas, New Hampshire, New Mexico, Pennsylvania, South Dakota, Texas, Utah, and Wyoming. The rest keep a permission slip; incumbents often intervene. That is how a must-have emergency department stays the only door. Oklahoma is not on that ‘none’ list; Surgery Center of Oklahoma still posted a cash menu there — ambulatory, not a second trauma tower. The plant page uses the no-certificate-of-need set as the hunt board, not a claim that Oklahoma forbids a hospital.
Source: National Conference of State Legislatures, Certificate of Need (CON) State Laws; American Action Forum, Certificate of Need: The Scope and Impact of Health Care Supply Restrictions.
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Cost Plus Drugs posts acquisition plus a fixed markup
Mark Cuban Cost Plus Drug Company, PBC: a public-benefit corporation that vertically integrates manufacturing, wholesale, mail-order pharmacy, and a pass-through pharmacy benefit (UnPBM). Online pharmacy: acquisition cost plus a fixed 15% margin, plus a pharmacist review fee and shipping — the breakdown is on the product page. Wholesale/Marketplace passes supplier pricing with a thin published markup (Cuban has described hospital Marketplace in the high-single-digit percent). Dallas sterile fill-finish (opened 2023) targets shortage injectables. This is a posted SKU, not a new insurer. It does not replace a must-have emergency department.
Source: Mark Cuban Cost Plus Drug Company, PBC, markcubancostplusdrugcompany.com and costplusdrugs.com (pharmacy, wholesale, UnPBM, manufacturing). Ground Truths interview with Eric Topol, December 2024 (Marketplace markup and Dallas plant).
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Clout opened meetings. Generic factories already sell.
Alex Oshmyansky (Becker’s Hospital Review, on the Community Health Systems Marketplace deal): Cost Plus has direct relationships with 38 of the 40 largest generic manufacturers, and as a wholesaler it often pays manufacturers more than bigger distributors so makers are not forced into a race to the bottom. That is the opposite of a celebrity discount on the factory invoice. Brands are the lock: Fierce Healthcare quotes Cuban that the big three pharmacy benefit managers tell brand manufacturers not to work with Cost Plus; he has said the Ozempic manufacturer will not sell through them. On LinkedIn he wrote that Cost Plus cannot buy rebated brands at a competitive price, cannot even get a walk-in-off-the-street price, and that one brand chief said they would not sell until Cost Plus covered half the lives the big three cover — because offering that price would cost formulary placement on the whole portfolio. A no-name still needs a wholesaler and pharmacy license. After that, commodity generics sell; brands still say no to Cuban.
Source: Becker’s Hospital Review, ‘All 71 CHS hospitals to use Mark Cuban’s drug wholesale services’ (Oshmyansky on 38 of 40 generic makers and paying manufacturers more). Fierce Healthcare, Cuban on brand manufacturers and the big three pharmacy benefit managers. Cuban LinkedIn post on branded meds, walk-in price, and ‘half’ the lives. TheStreet / Yahoo: Cuban on Ozempic — manufacturer will not sell through Cost Plus.
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Cost Plus bought as a wholesaler and rented the pharmacy
Nobody is granted a private right to a prescription molecule. The Drug Supply Chain Security Act lets licensed manufacturers, wholesalers, and pharmacies trade with other authorized partners. Mark Cuban Cost Plus Drug Company was a Texas wholesale prescription-drug distributor (WFAA Verify; Florida and other state licenses also posted). Oshmyansky: the company sells to a partner pharmacy; at launch that was Truepill, licensed as a mail-order pharmacy in every state, National Association of Boards of Pharmacy digital-pharmacy accredited — Cost Plus itself had not applied for that accreditation (WFAA). January 19, 2022 press: Truepill powered the site and fulfillment. June 2023: HealthDyne partnership to expand pharmacy operations. Company site: licensed drug wholesaler nationwide; prescriptions fulfilled by URAC Mail and Specialty accredited facilities. Cuban to NBC 5 Dallas-Fort Worth: more than three years going through the requirements. Oshmyansky incorporated the public-benefit corporation in 2018 (Osh’s Affordable Pharmaceuticals); Delaware records, name change to Mark Cuban Cost Plus Drug Company in 2020 (Snopes). HFMA: wholesaler licenses in all 50 states, mail-order operated with Truepill. The Dallas sterile plant is a later Food and Drug Administration manufacturing hoop, not the day-one mailbox.
Source: WFAA Verify, ‘Yes, Mark Cuban did start a real online drugstore’ (Texas wholesale license; Oshmyansky on selling to Truepill). PR Newswire, January 19, 2022 launch. HealthDyne / Cost Plus PR, June 7, 2023. NBC 5 Dallas-Fort Worth, Cuban on three-plus years of requirements. HFMA interview with Oshmyansky (50-state wholesale; Truepill fulfillment). Snopes / Delaware records on 2018–2020 name. markcubancostplusdrugcompany.com (wholesaler; URAC Mail and Specialty).
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Pharmacies had websites. Usual and customary blocked the list.
Pharmacy-benefit-manager network contracts typically reimburse the lesser of the contracted rate (average wholesale price discount or maximum allowable cost) and the pharmacy’s usual and customary charge — the cash price submitted on the claim. That lesser-of is why a low posted cash price is a gift to the administrator’s reimbursement desk and a threat to the shop. RXinsider and The Thriving Pharmacist: a low posted cash price can pull insured reimbursement down to that number, so shops keep the official cash sticker high to capture occasional winners against underwater generics. Relentless Health Value (Luke Slindee): lesser-of / most-favored-nation logic is why cash often lives on a coupon (GoodRx) instead of a public menu. 2018: Patient Right to Know Drug Prices Act (commercial) and Know the Lowest Price Act (Medicare) banned gag clauses — a pharmacist may tell a person cash is cheaper; they are not required to post a cost-plus list. The gag was the other police job: stop the member from walking out of adjudication. Cost Plus Drugs’ consumer shop launched cash, so it did not carry that Caremark book on the same register. National Community Pharmacists Association (Bloomberg Law): on the order of one independent closure a day in a recent year; members citing reimbursement. Team Cuban card is a side-door cash BIN with a posted dispensing fee, not a rewrite of the shop’s usual and customary for the old network.
Source: RXinsider, ‘Setting a Successful Prescription Pricing Strategy: Usual & Customary.’ The Thriving Pharmacist, ‘Insurance and Cash Prices in Pharmacy’ (2018). Relentless Health Value episode 520 / Luke Slindee on lesser-of clauses. Pharmacy Times / Epstein Becker Green on the 2018 gag-clause bills (Patient Right to Know Drug Prices Act; Know the Lowest Price Act). Bloomberg Law on National Community Pharmacists Association closure counts. Cost Plus Drugs affiliate / Team Cuban card dispensing-fee schedule (Dispense Times). January 2022 Cost Plus launch as cash consumer pharmacy.
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Walgreens settled a usual-and-customary club case. That is why they did not post Cost Plus.
Walgreens ran a Prescription Savings Club: a membership fee, then cheap 30-day generics ($5 / $10 / $15). Plaintiffs in Russo v. Walgreen Co. (N.D. Ill.) alleged Walgreens kept those club prices out of usual and customary, so insured customers and plans paid more than club members — the two-list move: cheap cash, higher insured. Walgreens denied wrongdoing and said it correctly reported retail as usual and customary. Reuters, November 4, 2024: Walgreens agreed to pay $100 million to settle; settlement class period through November 18, 2024; the club ended. Pharmacy-benefit-manager contracts and federal Medicaid lesser-of treat usual and customary as a ceiling: you do not collect the higher contracted rate when a lower cash price exists. Posting a public factory-plus-15% menu would declare that number as usual and customary at every store. The club was the attempt to sell cheap cash without rewriting that sticker. CVS ran the same pattern with Health Savings Pass; Corcoran and related cases allege CVS did not report pass prices as usual and customary, including to Caremark, which CVS owns. CVS denies it. Drug Channels: Walgreens has stayed in preferred Part D networks. A chain cannot fire the insured book the way Cost Plus launched cash.
Source: Reuters, ‘Walgreens agrees to pay $100 mln to resolve lawsuit over generic drug pricing’ (November 4, 2024). Russo et al. v. Walgreen Co., settlement notices at savingsclubsettlement.com (Prescription Savings Club vs usual and customary; Walgreens denial). Corcoran / Sheet Metal Workers notices on CVS Health Savings Pass and Caremark (allegations; defendants deny). Drug Channels on Walgreens preferred Part D network participation.
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Cuban on X: cash often beats the ‘negotiated’ rate
Cuban’s X posts, as quoted in trade press: a cash CT at a freestanding American College of Radiology site versus hospital outpatient; self-funded shops should pay the out-of-network provider the cash rate instead of letting the administrator bill the higher figure (Radiology Business). Separate August post: if you cannot afford the deductible, the financed cash price may beat the job-plan rate — find a doctor who takes the card. He repeats the same stack in interviews: fire the black-box pharmacy benefit manager, own the claims, direct-contract care, pay cash plus reinsurance. This project treats those posts as the formula, not as a claim that the plan invents the hospital’s 2–3× Medicare night.
Source: Radiology Business, ‘Mark Cuban comments on price variation in radiology’ (quoting Cuban on X). AOL/finance write-ups of the August deductible post. Ground Truths / Topol, December 2024. Sykes & Company interview on Cost Plus Marketplace, Team Cuban card, and cash-plus-reinsurance at his companies.
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Physician pay is skewed. It is not a 5/50 distribution.
Gottlieb, Polyakova, Rinz, Shiplett, and Udalova match the US physician registry to IRS tax returns. Among physicians ages 40–55 in 2017, mean total individual income was $405,000. The top 5% (cutoff $960,000, mean $1.817 million) account for 22% of physician pay; the top 1% (cutoff $1.94 million, mean $4.05 million) account for 10%; the top 25% account for 54%. The mean above each cutoff is about twice the cutoff — a Pareto shape of about 2 in the top half. Capturing half of physician pay takes the top ~22% of physicians, not the top 5%. Business income is the tail: 85% of top-1% income is non-W-2 vs 6% for the average physician. Aggregate physician earnings were 8.6% of national health spending in 2017; about 25% of Medicare physician-fee revenue accrues to physicians personally. Survey data (ACS, Medscape) understate the tail because they miss business income.
Source: Gottlieb, Polyakova, Rinz, Shiplett, Udalova, ‘The Earnings and Labor Supply of U.S. Physicians,’ Quarterly Journal of Economics 2025 (Table II). CMS NHEA 2017 via that paper (physician earnings = 8.6% of NHE).
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Hospital CEO pay is more concentrated than physician pay, still not 5/50
Mulligan, Nikpay, and Young (PLOS One 2024) merge Candid Form 990s with hospital cost data. In 2019, 868 nonprofit hospital/system CEOs averaged $1.3 million. The top decile averaged $5.62 million and held 44% of CEO pay; the bottom decile averaged $149,000. The page’s top-5% share (~34%) and ‘~15% of CEOs for half of CEO pay’ invert a Pareto tail (α ≈ 1.56) from that measured top-decile share — not a microdata Lorenz curve. Baker Institute (2015–2022 990s): at the largest 10% of hospitals, CEO pay rose to $6.31 million vs $121,000 for direct-care staff (51:1). Cause IQ: among 1,593 nonprofit hospital CEOs, average total compensation $660,000 and the top 5% cutoff $2.00 million.
Source: Mulligan, Nikpay, Young, ‘The determinants of nonprofit hospital CEO compensation,’ PLOS One 2024 (2019 Form 990s). Baker Institute, ‘The Growing Gap Between Hospital CEO and Direct Care Pay’ (2015–2022). Cause IQ, Compensation of CEOs at nonprofit hospitals.