Challenge HN: Let a suit evaluate your project - <AUTHOR>

This post is meant to settle a friendly argument between myself a few hacker friends of mine. I am a 'hackersuit.' I have a business degree & work in business development. I can also hack enough to contribute to the product I work on at a valley giant.
I taught myself to code over the last few years b/c I was tired of the attitude I got from hackers when I talked about concepts & ideas. Now I only appreciate what hackers do more.
There are two premises that motivated me to write this post:
1) I believe that both suits and hackers under-appreciate each other. The lack of symbiosis is the reason most start-ups & projects go nowhere and/or fail.
2) Hackers pigeon-hole business folks just like suits do hackers. Suites think that any ol' hacker can just 'write some code' and build their product; hackers think any suit can 'do some marketing or sell the product.'
Neither is true.
What I'd like to demonstrate to hackers is that some suits (like some hackers) have 'it.' Call it intuition, business savvy, a sixth sense, whatever. It's the ability to determine whether an app, website, concepts, etc. has market value or potential.
So the idea came up to use HN to ask people to share what they're working on and then have me - the suit - give VC-style, pinpoint feedback to show why/how whatever project does/does not work in the market
Our goal here is to a) prove the importance of some suits - those with 'it' - to the conceptualization & execution of a project, and b) dispel the theory that any hacker can just 'create something and turn it into a business.'
But, the larger aim is to prove that if we want to move ourselves forward, we're going to have to develop a much healthier respect and appreciation for each other - hackers and suits.
So, if you're up for it and have a relevant, project post your MVP, app, site, whatever and I will break it down. <comment><USER2> That sounds interesting. In that case, I would be interested in getting your perspective on the market value and potential for this MVP that I released recently: <http://www.habbit.me>

It's an app where your objective is to build your ideal future selves by mastering the habits needed to bring them into reality (in the present you). For now, it's an experiment to try and make habit-building more engaging and durable since changing personal habits are difficult to do in the long run.

<comment><AUTHOR> What's the target age for this? The imagery is very juvenile, and although can be thought of as nostalgic, comes off as either condescending or not serious.

Some blunt feedback: the premise is there, sure, but nothing about this gives me any inclination that there is something worth purchasing here. There's no explanation of how you "build your best future," what that entails, etc.

A few misc. thoughts:

\--Future self sounds very "Matrix-y" and is overwhelming \--The imagery is just too young \--The "pay what you want to" model is interesting, but the foundation is providing excessive value. You have to make the case first that this is worth it... \--There is a bug where if you scroll past the "add name" shot you can't go back. So, I got stuck there and am not sure what actually happens.

The self-help market is big and there is opportunity, but you need to clarify the message about your "system" or whatever it is that's going to work. This market is made by building a brand around your advice -- think about Atkins Diet, Tae Bo, 7 Habits -- and while the web component and "exploration" components are interesting, there's nothing that sticks or stands out, especially to an adult.

</comment></comment><comment><USER3> This sounds interesting. I definitely need some feedback on my app Finderous. It's a location based groups app where users can start their own groups or join other interest groups. the app can be downloaded at <https://itunes.apple.com/us/app/finderous/id520384764?mt=8>

</comment><comment><USER4> Sure, I'm game (admittedly because right now I value any-and-all feedback ;)).

The core idea isn't very original - live chat for websites - but the tool itself is slowly picking up momentum, albeit whilst under heavy development from me: <http://track-chat.com>

<comment><AUTHOR> The question is not about originality, but about competition.

\--The market is dense and success comes down to having a better customer acquisition strategy. Your ability to acquire customers -- meaning, generate cost-effective traffic, convert customers, retain them -- is what will make or break this as a business.

\--I don't see a clear value proposition for your service over the many, many competitors. Maybe this is because of the sheer quantity of text (very hard ont he eyes), but after browsing the site nothing tells me why I should select your service rather than go Google "chat services."

\--SMBs are your target market. But, the people who run these businesses do not have the time to sit and chat with customers. They are bound to look at this and feel they have no time to do it and give up.

My advice:

\--Tighten up the website. Less text, more images, clearer value proposition. Why is TrackChat the best option?

\--Show me numbers. If I'm a website owner, I'm craving to read about how another business made more money or improved conversion rates doing this.

\--Pursue potential partnerships with a service business that can support you. If you can connect businesses to people who can operate these chats, your value to customers multiplies exponentially.

\--After the above, develop and execute an acquisition plan ASAP. SEM is going to be your best option. Remember, your customers don't need technical sophistication; it's going to be hard for you not to indulge your engineering instincts but you have to realize your customers just need an application that is easy to set-up, works consistently, and does what it says it will.

This has potential if you can tighten up the site experience and are willing to make the investment in bringing in customers. They will show you quickly what you still need to build. If "word of mouth" is swirling somewhere in your thoughts, that's a huge red flag.

<comment><USER4> Fantastic, thanks, that's some really good advice you've given me, and I really appreciate it.

One minor quibble: "Less text, more images" is not compatible with "SEM is going to be your best option." Without a good amount of text, there's very little for the SEs to work with.

However, the copy does need to be tightened up, more images would be ace, and it should be possible to highlight value propositions without requiring the reader to scan through pages and pages of text, so it's still given me a push in the right direction.

 _If "word of mouth" is swirling somewhere in your thoughts, that's a huge red flag._

Could not agree with you more on this. "Word of mouth" is _not_ a viable strategy :)

Lots to work on, thanks!

<comment><AUTHOR> SEM != SEO. Paid search (AdWords, etc.) is going to be your best option. Terms like "website chat software."

(Also, SEO primarily does only look at text on pages, but metadata, third- party links, etc.)

Glad this was helpful, best of luck!

</comment></comment></comment></comment><comment><USER5> This will be interesting... habitrpg.com

</comment><comment><USER6> My stuff is already released ( with more to come ) www.kidoteca.com

<comment><AUTHOR> The apps look nice. Videos are solid and the product seems to be well built (without having seen the app itself).

Most important thing to keep in mind is that your target market is parents, not the kids. Your challenge is to convey why this is a valuable app for them to put in front of their children.

You waste real estate at the top of the page on things that are good for you and not the user. Half of the visible page is allocated to Facebook, subscriptions, and other linkage. Not a good user experience -- I'm not bragging about your app until I have it and love it.

If you believe in your product and the app is good, the biggest focus for you should be to get as many people to download at least ONE of your apps as possible. To that end:

\--If Matryoshka is free, TELL THEM and get it in their hands. If they like one of your apps, they'll download more and pay for them. Don't make the price a surprise, and highlight it if there is none.

\--Matryoshka is not a good name for an app. I can't pronounce it, which guarantees it will undermine my ability to tell other parents about it.

\--Nothing speaks louder than customer testimonials. Grab app store reviews and show them off so parents get interested.

\--I don't want to download apps via a desktop site. Why don't you give people an option to text them a link for download, or otherwise get this link to their phones ASAP.

\--What if I don't want to watch a video? Give me pictures to look at.

This is a competitive space with a lot of power behind it. Being able to market your games is about differentiation and proving value. Parents will download anything if they think it will help their kids.

Rely on happy customers to grow your audience. You seem to have a decent Facebook/social following -- I'd focus on how to curate that base and incentivize happy customers to share with others.</comment></comment>


Yahoo Ad Network Hack Should Be the Nail in the Coffin for Adobe's Flash - <AUTHOR> http://arc.applause.com/2015/08/04/adobe-flash-vulnerability-yahoo-ad-network/

<comment><USER2> Continuing to use Flash at this point just seems to be laziness - why is anyone supporting it at all?

</comment><comment><AUTHOR> How do you kill zombies? Well, by smashing their brains out. </comment>


SpaceX's plan to fly you across the globe in 30 minutes [video] - <AUTHOR> https://www.youtube.com/watch?v=Dar8P3r7GYA <comment><USER2> I'm surprised they're talking bout having the landing pad 10km off shore--it seems like that wouldn't be far enough for noise reduction, both outgoing (rocket engines) and incoming (sonic booms).

<comment><USER3> Doubling the distance only gives you a 6db drop. So, the best approach is probably to have structures in the way to redirect sounds. Which should make a dramatic difference.

<comment><USER4> Unless the structure was miles high, wouldn't the sound just bypass it as it climbed above?

<comment><USER3> This mostly deals with ignition and static firing where the rocket is not moving. Rockets have ridiculous acceleration, but create a lot of noise on the ground. I assume being kind of noisy for 5-10 seconds a few times a day is not that big a deal.

Assuming ~20 stories aka 200 feet is reasonable at 100 feet per second acceleration aka just over 3 g's in 2 seconds the base of your rocket is just over the 20 story building and your doing 130 MPH. Even still that building is still going to be blocking a lot of sound as the fire is below that level.

7 seconds after launch your (5 after clearing the building) your doing 477 mph and have traveled 1/2 a mile. At 12 seconds your doing 820 mph and have traveled 2 kilometers up.

PS: Falcon Heavy is apparently ~160db vs 120db for thunder, which you can barely hear at 10km. So, it's going to be noticeable at 10km, but not that noticeable.

</comment></comment></comment></comment><comment><USER5> There is definitely a market for this. When you hit really high levels of the corporate or governmental world, time becomes enormously more valuable than money. The market might bear a cost many times that of a private jet flight if the time were this short.

This is an incredible idea for subsidizing the Mars rocket program via rapid transit for executives, heads of state, etc.

Of course it would also have to be demonstrated to be at least as safe as air travel first before it would hit the mainstream in that market.

<comment><USER6> I have yet to see any mention of how the passenger experience is going to be. I assume it is much worse than some ear pain on take off and landing. Can the average person handle this trip comfortably? Or do they have to pass some astronaut-like conditioning test?

<comment><USER7> > Or do they have to pass some astronaut-like conditioning test?

I wonder about military applications. One would imagine that special forces groups would meet requirements. Being able to move SEALs around the world in a matter of minutes would be a boon for force projection.

<comment><USER8> Rocket launches take a certain amount of planning and favorable weather. Plus, they are impossible to hide. All in all, not desirable.

<comment><USER7> Ah, I forget that rockets are no where close to planes...

At best one could _maybe_ speed up pre-planned movements, as opposed to allowing a QRF to more rapidly react.

</comment></comment></comment></comment></comment><comment><USER9> This, combined with all the tech needed for a Mars colony, would make it trivial to build a permanent settlement in Antarctica.

A domed, self-sufficient, city in Antarctica would also be a cheap way to test most (not all) of the tech needed for Martian self-sufficiency, along with the psychological impact of living in a desolate wasteland where rockets are the only way in or out, and it would be a good insurance policy against many possible global catastrophes.

<comment><USER10> Landing on ice, with a rocket firing down.

You sure?

<comment><USER9> Question (I don't know if the answer is known to anyone, nor where to look online): does Mars have significant CO2 permafrost that can be disturbed by landing a rocket on it?

<comment><USER10> > This, combined with all the tech needed for a Mars colony, would make it > trivial to build a permanent settlement in Antarctica.

> A domed, self-sufficient, city in Antarctica would also be a cheap way to > test most (not all) of the tech needed for Martian self-sufficiency

GP is talking about testing the rockets in Antarctica.

<comment><USER9> I am GP. I'm talking about testing colony tech somewhere where failure isn't fatal. Rockets are only part of that, but it's not really testing by the time you have the rocket capacity to make a colony in Antarctica.

</comment></comment></comment></comment></comment><comment><USER11> > and the longest part of the trip is the boat trip

In other words, how to make human pancakes in 30 minutes.

But really, these are ballistic trajectories. Are we going to put everyone in G suits? And you're going to really restrict who can/will go on. They will likely go slower, so everyone doesn't have to go through endurance training.

Plus, being 5k-10k out from land, the total trip is definitely going to take much longer than 30 mins (yeah shorter than the airline flight), to get people on to the boat, onto the rocket, baggage loading, etc. It takes about 30 minutes between when they start loading people onto a plane and when they take off (and baggage is already on!).

Let's be real, if they get it working, it will be 2-3hrs trip. Which is still great, but not 30 minutes.

<comment><USER12> >But really, these are ballistic trajectories. Are we going to put everyone in G suits?

I assume you mean because minimum-energy ballistic trajectories[1] come into the atmosphere very steeply, so the G-forces are much higher.

But by using flatter trajectories (closer to an orbit than a parabolic "hop"), you reduce the angle of entry considerably, at the expense of using more fuel.

The result is that for Earth-to-Earth rockets, essentially all trip distances require the same amount of fuel.

>It takes about 30 minutes between when they start loading people onto a plane and when they take off (and baggage is already on!).

I wonder if they can pack baggage into a lightweight "carriage" during the boat ride, the simply load that single carriage onto the rocket. Or even a few carriages.

It will incur a mass penalty ("box within a box"), which means fewer passengers. But if it speeds up total trip time it could improve competitiveness with long-distance plane trips.

Either that, or just force everyone to buy SpaceX-brand standardized luggage that's ultra mass-efficient and supports automated handling/loading. :)

[1] [http://hopsblog-hop.blogspot.com/2014/06/travel-on- airless-w...](http://hopsblog-hop.blogspot.com/2014/06/travel-on-airless- worlds.html)

<comment><USER13> You mean pack baggage in containers like the ones already used for cargo on large passenger aircraft?

[https://en.wikipedia.org/wiki/Unit_load_device](https://en.wikipedia.org/wiki/Unit_load_device)

<comment><USER12> Yes, that's exactly why I thought of it! Thanks for the link.

If it makes sense for airlines, it stands to reason that it probably makes sense for rocket-based passenger travel too. Though I expect the containers will be even more heavily mass-optimized than those used on airplanes.

</comment></comment></comment></comment><comment><USER14> Ah, the HOTOL from the 80s.

<comment><USER15> Completely dissimilar except for being a cylinder with stubby wings. It's not single stage to orbit, it's vertical launch, it only has rockets not an air breathing engine, It's not a space-place, and it's interplanetary. Much simpler and builds on established technologies.

</comment></comment><comment><USER16> Can somebody tl;dr what is new in there? I tried jumping through the video, but there seems to be a lot of fluff and background exposition for the assumed "not in the loop audience" of TED. So I'm not sure where some new stuff starts, if at all, for someone moderately aware that Falcon Heavy did succeed, and BFR is planned?

<comment><USER17> Nothing new, all from old footage.

</comment></comment><comment><USER18> This has been addressed and debunked by: [https://en.wikipedia.org/wiki/Phil_Mason](https://en.wikipedia.org/wiki/Phil_Mason)

My apologies for not including the link:

[https://www.youtube.com/watch?v=j4KR4-TN- Yo](https://www.youtube.com/watch?v=j4KR4-TN-Yo)

He raises excellent points imo.

<comment><USER19> For a guy working as a "scientist" he's pretty ignorant when it comes to basic chemistry.

His "debunking" of Goodenough's battery shows that he doesn't understand the difference in the way energy is stored in carbohydrates vs batteries.

<comment><USER18> He has a PhD in chemistry. I don't know about the Goodenough's battery debunking, but imo his analysis on BFR Earth-Earth flights is spot on.

<comment><USER19> > He has a PhD in chemistry.

If that's so then I find his videos intentionally misleading and remain skeptical.

Edit: added newline.</comment></comment></comment></comment>


Best Free NYC Subway Commuter App - <AUTHOR> https://itunes.apple.com/us/app/quick-stop-nyc/id639340128?mt=8

<comment><AUTHOR> I love this app because it's simple and lets me just get train arrivals for my favorite stops. I don't have to tell it where I'm going or anything. I've used the NYC subway system my whole life I don't need a routing app and I find them annoying.</comment>


Lego Carcassonne - <AUTHOR> http://www.iamcal.com/lego-carcassonne/ <comment><USER2> This is beautiful. I like the extra work done to make sure tiles only fit together if they may be legally placed next to one another.

<comment><USER3> However, it makes it difficult to drop a cloister into just the perfect spot...

<comment><USER4> That is true whenever the piece will be matching two different sides, you'll have to pull it apart on at least one line (column/row).

However, since the pieces slide together instead of locking together I don't see that as much of a problem.

The bigger problem would be pulling them out of the sack at 'random' :D

</comment></comment></comment><comment><USER5> Wow! $2000 for a set! I had no idea custom sets of Legos were so pricey, even at 72 tiles that seems like a lot, given that the blocks used are pretty basic.

<comment><USER6> Buying individual blocks from Lego has always been crazy expensive.

<comment><USER7> I've heard of people arbitraging the market by buying retail sets, unbundling them and selling individual blocks.

</comment></comment></comment><comment><USER8> Those are _stunning_ renders. Mind you, Lego plastic is slap in the sweet spot of what a ray tracer ought to be good at, so I guess it's not surprising.

</comment><comment><USER9> Absolutely Awesome! Love Carcasonne and love Lego ;) yes, i'm a big kid! ;)

</comment><comment><USER10> Very nice. I'm not familiar with the game, but I spent a couple of days in the real Carcassonne and it is amazing. If you can find a hotel room in the city walls it is well worth it.

<comment><USER11> Only if the walls completely enclose the space.</comment></comment>


Haskell 2010 Accepted Papers - <AUTHOR> http://www.haskell.org/haskell-symposium/2010/accepted.html <comment><USER2> So much good stuff in there. Brian O'Sullivan mentioned his paper on the GHC event manager on his blog:

[http://www.serpentine.com/blog/2010/06/14/sightings-of- the-g...](http://www.serpentine.com/blog/2010/06/14/sightings-of-the-ghc- event-manager-in-the-wild/)

He also linked a preprint:

<http://www.serpentine.com/bos/files/ghc-event-manager.pdf>

There are also plenty of discussions on the mailing list.

<http://groups.google.com/group/ghc-io-manager>

Brent Yorgey is of course the current editor of The Monad.Reader, and the author of the Typeclassopedia, so I'm looking forward to his paper too.

<http://www.haskell.org/sitewiki/images/8/85/TMR-Issue13.pdf>

<http://themonadreader.wordpress.com/>

<http://byorgey.wordpress.com/></comment>


Music for Programming - <AUTHOR> http://pileofturtles.com/2010/12/music-for-programming/

<comment><USER2> Soma.fm Tag's Trip progressive house / trance is my audio lubrication. Always changing, never dull, and you may discover a few new favorites to purchase. It's free to listen, but appreciates donations.

<http://somafm.com/>

Secret Agent can als be quite good.</comment>


Eduard Pernkopf: The Nazi book of anatomy still used by surgeons - <AUTHOR> https://www.bbc.com/news/health-49294861 <comment><USER2> Oof. Naturally the idea of distributing scanned copies of the book for educational and professional purposes comes to my mind and the article really gives me the feeling that mankind would greatly benefit from it. But you just can't ignore the sinister origin. The photo of the author and his illustrators lets me shiver. This is a textbook example of a dilemma.

<comment><USER3> If only we had thousands of bodies donated to educational institutions for decades with the capability to reproduce these works in better fidelity with modern technology. Oh well, I guess we will just rely on this Nazi book instead.

</comment></comment><comment><USER4> To do away with any good done, just because evil was done, is sad and shortsighted. I am glad people can move forward without dragging around the past like a corpse. Annoyingly, much of our best tech of a certain era was developed by Nazis, but I sure as hell am not about to unlearn rocket science as a consequence.</comment>


Heart Surgery in India for $1,583 Costs $106,385 in U.S. - <AUTHOR> http://www.bloomberg.com/news/2013-07-28/heart-surgery-in-india-for-1-583-costs-106-385-in-u-s-.html <comment><USER3> The first supposed fact thrown around in the medical costs argument like this is, "Well in India their cost of living is lower, so they charge considerably less, yadda yadda..." but it's obvious the price difference goes way beyond any cost of living gap. That's over $100,000 in price difference, while it is true the cost of living (salary, prices of every day items) in India is considerably less than that of the US, the gap certainly isn't 100k+

It's comparisons like these that really make you sick to your stomach. You don't see this kind of innovation in the American health system because it has been engineered with greed in mind right from the start. The lobbyist super groups, hospitals being paid kickbacks for using an exclusive medical equipment provider, the money hungry mentality of US medical corporations is more than obvious.

I think when your medical system becomes so expensive it's cheaper for people to fly out of the country, pay for accommodation and even some spending money to get the same level of care, if not higher than that of your own country, regardless of cost of living differences and other nation specific costs that's absolutely ridiculous. By the sounds of it, India is going to be the new global superpower if more and more people fly there to pay for medical treatment it benefits their economy in the end (given how a substantial chunk of the population is below the poverty line, this might not be such a bad thing).

A doctor trained in India is no less qualified than a doctor trained in the US. So expertise or training is no excuse either. In-fact I've found Indian trained specialists to be more thorough, careful, understanding and compassionate in comparison to that of Australian trained medical professionals (I'm from Australia). When was the last time you saw or heard of a poor American medical specialist or surgeon?

The question is: Will America ever change their ways? Or will quality medical care only be reserved for those who can afford decent medical insurance or have jobs that provide fair medical benefits?

One thing is for certain, this is submission is going to garner a lot of responses from both sides of the fence if past submissions along these lines are anything to go by.

<comment><USER4> >>You don't see this kind of innovation in the American health system because it has been engineered with greed in mind right from the start.

As an Indian, I can tell you people here think the same about our health care system. The Doctor in discussion here, Dr Devi Shetty is a sort of a local hero here in Bangalore. And who knows in some years he might as well be a national hero. Its basically because he seems to bring in advantages of doing things in volume + some health insurance based innovations into the whole equation. And I do agree that he is pragmatically altruistic. But such people are exceedingly rare. We are simply fortunate to have him.

I've never been to US, but I can tell you the Indian health care system is if not less is equally greedy compared to their US counterparts. Its just the same.

These days if you don't have health insurance you are more or less screwed. Its just like the US. I mean from whatever I've read about US so far its the very same. Nothing changes. You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x value of your money. That is what it is at the end of the day.

Coming to our system. Forget greed, fraud in the system is so massively high nothing that I write here will explain it. It is extremely common for doctors to order lab tests wholesale even if they are dead sure the patient has no problems at all. Doctors get commissions from testing labs/pharmacies etc for ordering lab tests, medicines. Treatment is purposefully prolonged, patients made to eat all kinds of antibiotics, undergo all sorts of non sense tests because doctors get commissions for it.

The fees for completing your medical course is astronomically high. Capitation fee often runs in crores, the net fee by the time you finish your MD is so high no doubt most doctors have to practically turn into crooks to get something out of it. Add to this nearly more than a decade of studies sets a perfect stage for these sort of activities to happen.

Its just the same old game, as you see in US. Just served differently.

<comment><USER5> > You just feel its cheaper as $1 = 60 rupees. There you get a straight 60x > value of your money. That is what it is at the end of the day.

I find the vast majority of people are tripped up by currency conversion, but I'm surprised to find this on HN. In Japan $1 = 100 yen, but certainly I don't feel I have 100x in buying power. A bowl of ramen will cost me $8 in SF; an equivalent bowl will cost me 800 JPY in tokyo.

Let's not even get started on the Korean Won...

<comment><USER6> I'm surprised that how many otherwise smart people gets tripped up by this. The only time you can deduce something from the exchange rate is if you compare the difference between the two rates over a longer period of time. Then it can roughly tell you things about difference in direction of inflation between the two countries, and the effect on wages and imports/exports. If the difference between the exchange rate between two countries doesn't change for a long time the prices of goods in both countries end up being roughly the same.

<comment><USER7> "If the difference between the exchange rate between two countries doesn't change for a long time the prices of goods in both countries end up being roughly the same."

Simply not true. Compare the cost of a beer in, say, Thailand and Norway. Are you suggesting if the exchange rate were fixed they would reach parity over time?

<comment><USER8> Assuming no new disruptions, then yes, economic conditions in the two countries would eventually equalize and prices would differ by at most the shipping cost if one of the two countries happens to have much better natural conditions for producing beer than the other. It's because disruptions are now becoming (have become?) the norm that equilibrium never has time to come close to manifesting itself.

<comment><USER9> Alcohol is a poor example because of special taxation.

The Big Mac index is better for many reasons, one being Mcdonalds is large enough to mostly optimize everything wherever they operate:

[http://en.wikipedia.org/wiki/Big_Mac_Index](http://en.wikipedia.org/wiki/Big_Mac_Index)

</comment></comment></comment></comment></comment></comment></comment><comment><USER10> Probably not going to get seen in this morass of comments, but I went back and reviewed the CMS data that the article cites.

The article used the Diagnosis Related Group (DRG) 238 - Major Cardiovascular Procedures without Major Complications. This is the best guess at capturing the costs of "Open Heart Surgery". (CMS only releases data for the top 100 DRG codes). "Open Heart Surgery" is a term for a variety of surgical procedures done on the heart, including valve replacement, vascular repairs of the aorta/vena cava/pulmonary vessels, and coronary bypass. These span a wide variety of DRG codes, including 216-221 for valve replacement, 228 (other cardiothoracic procedures with major complications), and 231-236 for cardiac bypass. Assuming we are comparing the operation known as coronary bypass grafting, then 238 is a decent enough code to use, with the proviso that it's not the best source for data.

Looking at the numbers claimed: If you download the Excel file from CMS [1], you can sort by DRG and Provider Name. Yes, if you search by DRG 238 and filter by Cleveland Clinic you will get $106,385 charged to Medicare. However, what the article completely leaves out (and anyone in medical practice will assume) is that Medicare simply does not pay the amount covered. Average Total Payments by Medicare: $26,898. That's how much Cleveland Clinic gets reimbursed, on average, by Medicare for any procedure included in DRG 238.

It gets more interesting when you include all providers and sort by average total payments. The highest average Medicare reimbursement to anyone for DRG 238 is $54,682; the lowest $13,233. Another interesting example:

In Alabama, at Brookwood Medical Center, DRG 238 covers $111,008 and only reimburses $15,552.

These comparisons of the US system to outside countries really need to compare average US reimbursement to their stated cost, because they sure aren't funding an army of administrators to get the insurance companies to pay up.

In summary, you can get "open heart surgery" in the US (Alabama) for "$15,552". I wonder what the Alabama price is if you walk in and offer to pay cash. If you can get it at the Medicare reimbursement rate, that compares decently to the Indian price.

[1] [http://www.cms.gov/Research-Statistics-Data-and- Systems/Stat...](http://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge- Data/Inpatient.html)

<comment><USER11> Why does the clinic charge that much to Medicare, if Medicare doesn't pay that much (legally, I presume)? Is it an accounting trick or something?

<comment><USER12> Well, probably a variety of reasons but certainly one key reason is... if you have to ask for 100K to get 25K, then if you ask for 25K your only going to get 8K?...

All prices are always negotiable, just that the individual consumer is so used to not having bargaining power that they forget this fact.

<comment><USER13> Medicare does not negotiate. The hospitals break down bills into CPT codes and get paid the published rate for the period for codes that are accepted (including geographic indexes and what not). It's a mess.

</comment></comment></comment></comment><comment><AUTHOR> I found it fascinating how this goes way beyond wage differences -- it's a serious focus on fiscal efficiency. The entrepreneur behind this has opened 21 new hospitals in India focused on bringing more affordable care:

"...he has cut the price of artery-clearing coronary bypass surgery to 95,000 rupees ($1,583), half of what it was 20 years ago, and wants to get the price down to $800 within a decade."

This leaves me wondering: Where is the innovation toward affordable care here in the USA?

<comment><USER14> Largely, on the lower end of the spectrum. Doc in the boxes for routine acute care, nurse practitioners substituting for doctors, pediatric medicine (+), etc.

\+ One business model is "Pay a flat fee of $50, cash on the barrel. Your kid gets to see a doctor in under 15 minutes. You know and we know that 98% of the time it's just your child being sick with a routine illness. We'll write the prescription if required and rule out anything more serious. If it is anything more serious, we'll explain your escalation options."

<comment><USER15> As a parent of young children, I very much appreciate this option!

</comment></comment></comment><comment><USER14> Somewhere there is a forum of doctors saying "Pfft, the US firm wants $100k for the patient records system and the Indian firm wants $1,000. Those greedy bastards! They live in a toxic industry which acts as parasites on us noble public servants saving lives every day. It serves them right to deal with international competition finally.

Let's go with the Indian bidder. What could possibly go wrong."

<comment><USER16> Not sure what you're trying to say here. You seem to be trying to defend the cost of a $100,000 operation by making a snarky comparison with outsourcing an IT project.

Is that actually what you meant?

<comment><USER17> patio11 has a long history of making snarky comments about how outsourcing to India should not be a concern to Western IT workers because the quality of Indian IT workers is much lower than that of Western IT workers and clients will ultimately recognize this and hire a Westerner instead. This is presumably something that is quite near and dear to him, as he is an American expat who lives in Gifu, a tiny, rural Japanese town. Since his primary income source (outside of Bingo Card Creator and Appointment Reminder) is doing consulting work for Western customers, it's very important to him that they pick him over Indian consultants based on how good he is, since hiring him presents all the same issues with respect to time zone, distance, etc. that hiring an Indian would.

He probably experienced a lot of difficulty initially in acquiring customers (who opted to go with the much cheaper, Indian consultants), which is why he has such an oversized Internet presence, including on Hacker News - it has helped build a brand for himself that isn't location-specific.

<comment><USER14> My long history of comments on the issue generally references my time at the old Japanese day job, where I was pressganged into dealing with our Indian subsidiary and asked to shepherd the five folks who came to work at our Nagoya location from it. This is what I was doing during three years of 100 hour weeks.

A more charitable read of my old comments would be "The project(s) were beset by communication issues, terribly managed by the Japanese company (which, in the fine tradition of Japanese companies, I'll take blame for since I was unable to resolve it despite trying), and additionally undermined by pervasive competence issues."

I'm not talking my book here. In the first place, I don't have a book, as I no longer consult. In the second case, Indian BPO firms are less competitive with me than Chinese take out restaurants: our target customers are different, our projects are different, our marketing methods are different, etc etc.

</comment></comment></comment></comment><comment><USER18> First, adjusted for PPP that is more like $3,000. Second, nearly all personal and professional services cost way more in the U.S. Try hiring a nanny in India versus the U.S. and compare the prices.

In any case, whenever you talk about prices, it's important to try and think about it in terms of supply and demand. Why might prices for similar services be lower in India? In both countries, the price for that heart surgery is roughly the same order of magnitude as the per-capita income. But the median Indian is living far closer to subsistence than the median American. India's population is 70%+ rural and slightly over 50% are dependent on agriculture. Heart surgery isn't really an option for the median Indian.[1] While it may be financially catastrophic for the median American, between insurance, Medicare, Medicaid, etc, it is an option for the median American. The net result is that demand for heart surgeries, relative to the population, is far lower in India.

At the same time, the supply of doctors is higher. Being a doctor is considered socially desirable in India, and as a result there is a good educational infrastructure in place and plenty of candidates.

Higher supply and lower relative demand = lower prices.

I bet you can explain a lot about the U.S. healthcare industry in terms of regulatory issues, etc, but the magnitude of the impact of that is probably the difference between the U.S. and the UK, not the U.S. and India.

[1] It should be noted that when people give anecdotal reports about what things are like in India, there is tremendous perspective distortion. People will often pretend like relatively well-off people living in the cities are the "typical Indian" when in reality they're probably in the top 10%. It's as if the vast majority of India, poor and rural, doesn't exist.

<comment><USER19> Another thing to analyze is what's called "diseconomies of scale" where costs and/or prices rise with scale. Also many countries subsidize the health sector.

</comment></comment><comment><USER20> Medical tourism has hurt most Indians. 1583 USD is almost 100k INR. The average per capita income in India is 1219 USD (72k INR). This figure too is very misleading, since poverty is a huge problem.

A very simple plotting with data from wikipedia and rudimentary extrapolation, shows that more than 1.1 billion Indian's annual income is less than the current cost of heart surgery. India's total population is 1.2 billion.

Medical tourism, though very fine for a lot of folks who want a cheaper alternative, is driving up the cost of medical treatments in India by leaps and bounds. This makes surgeries, that were already very expensive and out of the reach of most Indian's even more expensive and out of the reach of even more people.

Sources: [http://en.wikipedia.org/wiki/Income_in_India](http://en.wikipedia.org/wiki/Income_in_India) [http://en.wikipedia.org/wiki/Poverty_in_India](http://en.wikipedia.org/wiki/Poverty_in_India) Simpel graph of the poverty data : [http://imgur.com/JngiK8W](http://imgur.com/JngiK8W) (I used this to find the number of people with an annual income less than 1583 USD)

<comment><USER21> > Medical tourism, though very fine for a lot of folks who want a cheaper > alternative, is driving up the cost of medical treatments in India by leaps > and bounds.

Any evidence to back this up? Your links and statistics are about how this specific cost is still out of reach of a lot of people. I don't think anyone is debating that.

> This makes surgeries, that were already very expensive and out of the reach > of most Indian's even more expensive and out of the reach of even more > people.

The article shows how the cost of surgery has dropped over time, and their goal being to drop it further.

</comment></comment><comment><USER22> I've posted about this a LOT here on HN, because I live in a country (Uruguay) that has a good level of medicine and prices are way cheaper (heart surgery as described would be at least an order of magnitude cheaper than in the U.S.).

One possible explanation I came up with was:

U.S. hospitals have legions of well-paid administrators doing paperwork for insurance companies, which will have legions of people doing paperwork on their side, and government doing its bit, and lawyers doing their thing. All that money is obviously not going directly into healthcare, it's basically monstruous bureaucracy friction. I suspect "real" healthcare costs, even factoring expensive U.S. doctors, would be shockingly cheap.

There are also other "hidden" legal costs, such as the cost of malpractice insurance, and overcosts due to doctors being extremely worried about being sued over malpractice and ordering unnecessary tests.

Is there a "transparent" U.S. medical institution whose expense records could be examined to come up with where all the money is going?

That said, the article compares with Ohio's Cleveland Clinic, which is the most famous heart surgery clinic. Supply and demand alone will make heart surgery there an order of magnitude more expensive, regardless of actual costs. But I've heard most U.S. clinics arent that much cheaper.

[https://news.ycombinator.com/item?id=6077593](https://news.ycombinator.com/item?id=6077593)

[https://news.ycombinator.com/item?id=6019464](https://news.ycombinator.com/item?id=6019464)

[https://news.ycombinator.com/item?id=5763001](https://news.ycombinator.com/item?id=5763001)

(I was really surprised by that one, why ARE ambulances so expensive in the U.S.?)

</comment><comment><USER23> Can't resist posting this anecdote from Atul Gawande's (best known for his New Yorker medical pieces, such as the one about checklists) book, Better: A Surgeon's Notes on Performance...at the end, he describes spending some time in India as a visiting surgeon to see how innovation was possible in comparatively squalid circumstances. The Nanded hospital he describes below serves 1,400 villages, about 2.3 million people, with just 9 surgeons (Gawande says that'd be comparable to the state of Kansas having 9 surgeons):

[http://www.amazon.com/dp/0312427654](http://www.amazon.com/dp/0312427654)

note: _It 's a little OT, but I guess it's an interesting anecdote because it talks about how absolutely significant surgical innovation (not just, "good for the India masses") can occur in desperate situations. I have no idea if that applies to the state of the art of heart surgery in India._

\</comment><comment></comment><comment>

Among the many distressing things I saw in Nanded, one was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one patient with an ulcer so severe that the stomach's acid had eroded a hole in the intestine. But Nanded is in a part of the country where people eat intensely hot chili peppers, and patients arrived almost nightly with the condition, usually in severe pain and going into shock after the hours of delay involved in traveling from their villages.

The only treatment at that point is surgical. A surgeon must take the patient to the operating room urgently, make a slash down the middle of the abdomen, wash out all the bilious and infected fluid, find the hole in the duodenum, and repair it. This is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes.

When I later told colleagues at home about the operation, they were incredulous. It did not seem possible. Motewar, however, had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment. His department was able to obtain some older laparoscopic equipment inexpensively. An assistant was made personally responsible for keeping it clean and in working order. And over time, Motewar carefully worked out his technique.

I saw him do the operation, and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.

<comment><USER24> The key:

 _His department was able to obtain some older laparoscopic equipment inexpensively._

Thanks to high-cost health care systems elsewhere spending enormous sums on the latest & best equipment on a regular basis, older equipment capable of facilitating very good (albeit not best possible) results becomes inexpensive.

In all the sneering at the high cost of healthcare in some areas, the consequential benefits to others gets overlooked. If you want the very best, yes it will cost a lot; if you're willing to settle for good instead of best, you can leverage what those buying the best paid for. If you cut the high cost options, the good low cost options may very well become infeasible.

<comment><USER25> Is your claim that the existence of excellent high-cost treatment options drive down the price of moderate good ones in the present, or that the moderate-cost good ones were at one point paid for by being the excellent high-cost ones? The two claims have very different policy implications.

Overall, though, we should be skeptical of device manufacturers' claims that dumping more money into expensive equipment leads to better health. Most money sloshing around in the healthcare system is wasted (see, for instance, the recent counterintuitive Medicaid study results: increased health care spending doesn't necessarily equate to improved outcomes). If we could spend 50% of the money for 80% of the results, that'd be an amazing improvement. And that money could be spent on other quality-of-life improvers, which very well might improve overall population health more than that last 20% coming from complicated medical treatments.

<comment><USER26> I think his claim is both those things. The R&D of the goods was paid for when they were originally sold as high-cost excellent equipment. Now, the existence of even better high-cost treatment options drives down the price of the older originally-high-cost equipment.

</comment></comment></comment></comment><comment><USER27> It's not greed, it's a consequence of health insurance. Get rid of health insurance and prices would drop 10x.

<comment><USER28> Would they? Or would the poor middle class people not being able to afford cancer-treatment/heard surgery just have a considerably lower life-expectancy?

I am not sure, so I really would love to see the numbers/facts supporting your statement. Would love to learn of this magic fact. [cynicism end]

[Edit]: Typo

[Edit 2:] In Germany, with full health-insurance the cost for a Cardiopulmonary bypass are round about 30k €. So a lot cheaper, than in the US, despite health insurance.

Just wanted to present a fact, not let my comment stand as cynicism only.

<comment><USER27> First of all, I am sure the 106K figure is a phony 'list price' figure and not reflective of how much is actually paid.

Second of all, you ignore the incredible sums of money taken from the 'poor middle class' and handed over to the health industrial complex.

For most of this country's history [the USA], there was no such thing as health insurance. The poor got charity care and the middle class were able to pay.

Why do you think cancer treatment has to be expensive?

<comment><USER28> I am not stating, that it might drive prices down. As I would not be stating, that it might drive prices up.

I wouldn't do this, because I do not have the necessary facts to make such a claim.

If a health-insurance system would work right, the health insurance agency might have a lot of more leverage in this highly regulated market, then any individual paying for its own. But that is just an assumption.

Well your next statement regarding my ironic "poor middle class" is just that: a statement, without any facts to support it.

I was asking for facts to support your statements. I even did some preliminary research into the costs of comparable healthcare in Germany (where I am from).

I just wanted to learn, if a "no health care" system might work better and be cheaper, but I will not just believe your statements, as that would just go against everything, I value.

So I really beg you, to show me verifiable facts substantiating your statements. Please?

</comment></comment></comment></comment><comment><USER29> You would think more Americans would fly to India to get expensive medical procedures done. Or are there other issues that need to be overcome to do this?

<comment><USER30> A few things:

1\. People don't know about it.

2\. Are the outcomes comparable?

3\. Legal protection - you will have hard time suing Indian specialist in India and there won't be much damages to extract anyway.

4\. Age? A good chunk of people that need that types of surgeries are well covered by Medicare.

5\. You also need plane tickets, recovery time and at least one companion - <USER2> you may look at a lot higher total cost.

6\. Plain old fear/ racism.

And the moment it becomes common there will be the full media smear campaign, scaremongering etc

<comment><USER31> Besides, Cuba is closer. Canada is also a bargain compared to the US and you don't even have to violate state department rules.

However, ironically enough, the USA has a booming medical tourism industry also. At about 60-80k, it is only half as small as India (150,000), though nowhere near Thailand (1.42 million).

</comment></comment></comment><comment><USER32> Another case: I live in Poland and needed a knee surgery (arthroscopy). Costs: -visit to a doctor and diagnosis (30$ per visit) -MRI of a knee (135$) -surgery + one day stay in private clinic (1k$)

So now I wanted to pay for everything without help of our health care system because that would mean waiting. When I tell people in US MRI costs 135$ in Poland they just can't believe it and this is in commercial clinic so they make money here, it has nothing to do with national health care system as I didn't use any refunds.

<comment><USER33> Do you mind if I ask where you went for such a cheap arthroscopy? I'm possibly in the market for this procedure myself, trying to weigh all the options.

</comment></comment><comment><USER34> I can assure you that the doctors doing 1-2 CABGs per day are not making $30M-$70M/year.

Alas I don't know how much the hospital takes, but I know that there are ~500,000 CABGs per year. I suspect that we as a nation are not spending $50 billion annually on CABGs, but I could be off.

</comment><comment><USER35> \- The hospital industry is a monopolized cartel - you usually need the approval of existing hospitals in an area before you can open your own. \- The insurance industry is a cartel - there are extreme compliance costs that only a few big players can take care of. \- Employer provided insurance is subsidized. \- Most 'reform' of health care in the US has punished individual insurance holders while strengthening the employment-based insurance system further strengthening third-party payment systems including increasing lists of 'must-cover' mandates for health insurance. \- McCarran-Ferguson act exempted health insurance from a competitive national market. \- The culture and institutional incentives in US healthcare push towards extreme capital- intensive expenditures and cut down on labor-intensive expenditures even when its not cost effective for the procedures that the patients require. Hospital beds get more expensive per day while extremely unlikely to succeed procedures like proton therapy expand further.

This paper is very illuminating and comprehensive: [http://c4ss.org/content/2088](http://c4ss.org/content/2088). Please have a look even if you disagree with the solutions and the ideology of the author. I assure you it will be worth your time.

<comment><USER35> Let me also add licensing regulations that require MDs for routine procedures. Though nurse practitioners are becoming more involved and this is a good development. Another issue which HN commenters are aware of is the AMA's cartel monopoly on medical school seats to control the supply of doctors.

</comment></comment><comment><USER36> "greed" is generally a code word for "incentives are too complex for me to bother to try to understand."

</comment><comment><USER37> Jayadeva Institute of Cardiovascular Sciences and Research, a popular hospital in Bangalore, publish procedure charges (in Rupees) on their website. Might be interesting for comparison.

[http://www.jayadevacardiology.com/procedure_charges.html](http://www.jayadevacardiology.com/procedure_charges.html)

</comment><comment><USER38> Maybe it would make more sense to compare it to prices in Europe or other places with similar medical standards.

My guess would be $100k in the US is about $50k in other places. At least my travel health insurence charges twice the rate if I travel to the US compared to "rest of the world".

</comment><comment><USER39> This is over 94,000 Rupees. That is a huge amount of money in India. I'm not sure most people realize the cost of living difference between the two countries.

Case in point: I was in India (Chennai) for a week on business a couple of months ago. During that time (M-F), I had a driver who was dedicated to me. He took me to the office and back, and took me anywhere else I wanted to go. This wasn't a taxi service, he had nobody else to shuttle around. When I was working, he just waited around for me to call. The cost for all of this? US $25, for the entire week. That's what I paid the car service, so he's getting some amount less than that.

All this to say: These sorts of comparisons are not as dramatic as they seem.

<comment><USER40> That seems absurdly low. I stay in Chennai and typical taxi rates run upwards of 18Rs per KM (approx 0.48US$ per mile). I agree there is a considerable difference in the cost of living, but what you likely paid the guy was a tip for the entire week. Even assuming the car, gas etc. was paid by your company, the amount still seems low for a driver's fee for a week. My dad's driver makes 11,000INR a month.

94,000 Rupees is a lot of money in India but it is not so huge either. A small local doctor in a city will make around that money in a month.

(ps: If you actually had a guy driving you for 25$ in Chennai, do pass me his number. I will happily use him.)

<comment><USER39> All I know is what was on the hotel bill (Westin). It's possible that they had negotiated a rate with the service. I did tip, based on the guideline I was told, about 50 rupees per day.

</comment></comment></comment><comment><USER41> As an American. this makes me sad. Just sick to my stomach. It's just greed.

<comment><USER42> But its not _just_ greed. Greed is also whats driving the Indian entrepreneurs to try to offer the surgeries cheaply and en-mass. Its more than that. Its unfair exploitation, regulatory capture, raw corruption and senseless parasitism. Its greed mutated and run amok. Its what happens when you get greed wet and then feed it after midnight.

<comment><USER43> Actually, in this case it is not greed in India. The guy running the show is a `real hero'. But the US has plenty of self-less people, too.

</comment></comment></comment><comment><USER44> What is the survival rate in India after that procedure, comparing to the US?

My colleague _visited_ India and returned with a stomach flu, spent a week in a hospital.

<comment><USER45> So because your friend ate some bad food, that country's hospitals must be unhygenic? Yup, I totally see the correlation there.

I'm Australian, visited the US and got severe Salmonella poisoning in Vegas... the US must have really shocking road safety laws.

<comment><USER46> Same here, got salmonella in Los Angeles eating at a subway. Point being, you can get sick anywhere, other factors include your body getting used to new organisms.

</comment></comment></comment><comment><USER47> Just had heart surgery. It's closer to $170,000 here in the states. :-/

<comment><USER48> Just curious - How much was it covered by health insurance?

</comment></comment><comment><USER49> I believe that the high medical costs are exactly the result of Free market in the long run. Entities will always unite to get stronger, control the market and to do so they will support little by little laws that allow this. Just my 2c, but if you don't keep your laws and democratic institutions distant from the big money... the free market will transform in a legal monopoly.

</comment><comment><USER50> This is classic disruption at work. There are many procedures e.g. cataract surgery costs have come down but they are such cash cows that the prices were held high. India is doing this because skills can scale if there is a system of training. It wasn't too long ago when I read the Russians invented a factory-line method of doing eye-surgery.

<comment><USER51> Five years back,my father got both his eyes operated upon for cataract removal at Coimbatore,India as part of some free Eye camp program.This year, my mom had cataract in both eyes surgically corrected in a private hospital in North Kerala.They charged only Rs.9500/\- per eye,and the treatment was quite good.Now my Mom has 6/6 vision in both eyes.

</comment></comment><comment><USER52> People have mentioned the cost of MRI scans in the US.

How much would it cost to buy a bunch of scanners (full body, and bucket-type for arms and legs) and employ technicians to do the scanning and offer this as a service to hospitals?

You could have technicians working on shifts to have out-of-hours scanning.

The scans are provided in electronic format to the patient and to the doctors specified by the patient. The centre encrypts all the scans and stores them for X years to cover regulation and litigation.

There's a big capital investment cost, but you're not doing any actual medicine there (no interpretation of scans, for example) and so litigation risk is reduced. You can concentrate on churning people through the machines, you don't have to give way to emergency cases that need immediate scans.

And the price of a scan can be listed up front.

Is this a stupid idea? (Or is it already being done?)

<comment><USER53> You've framed it as consumer friendly but basically your hypothetical shop, on top of being another middleman, has gained a weak local monopoly on MRI's. That sounds like it's going to be bad for both consumers and hospitals which is why it would never happen.

As a sidenote the problem with MRI's isn't a lack of supply. A popular factoid a few years ago was that Pittsburgh had more MRI machines than Canada. Even if that was only half accurate it tells part of the story about high MRI costs.

</comment></comment><comment><USER54> When government enters any equation and starts over-regulating in the name of "poor" the poor must be actually worried. Indian healthcare system is no less greedy than that of United states, I know several examples where Doctors would perform needless surgeries, will recommend expensive surgeries for terminally ill patients (which makes death more painful) and so on.

Indian government is a big believer in state interference into everything but when it comes to healthcare Indian government's approach is different. Instead of telling private hospitals who they should be run, Indian government builds its own hospitals. Thus private hospitals are left on their own with very little government interference. Thus those doctors can experiment while being very open about their experiments.

</comment><comment><USER55> From the article it's not clear what the major drivers are in bringing down the costs. What I've gathered from the piece and another link posted in the comments:

* No air conditioning

* Buying used scrubs

* Buying in bulk, directly from manufacturers [1]

* Surgeons that work "typically work 60 to 70 hours a week" [1]

The additional link [1] seems to indicate that the innovation is simply volume. The highly-trained surgeons perform more surgeries, the expensive equipment is utilized more hours of the day, etc.

[1] [http://m.theaustralian.com.au/archive/business-old/the- henry...](http://m.theaustralian.com.au/archive/business-old/the-henry-ford- of-heart-surgery-devi-shettys-business-model-delivers-cheap-medical- care/story-e6frg90x-1225801548287)

</comment><comment><USER56> I'm not gonna go on the conspiracy road but the world is functioning on the wrong parameters. Instead of being a united civilization and help each other in order to advance to a higher level, we are fighting each other like lions for supremacy in every domain possible.

Our whole system is based on superficial needs and wants rather than focusing on what we really need as species/civilization.

How can we expect innovation and progress when we can't even cross the damn ocean without selling our souls...we can't even cross our own borders without special rules. Not to mention that racism is high in many countries. We are divided as hell. If an advanced race would watch us right now they would probably laugh hard and leave.

</comment><comment><USER57> In my country I know of a hepatologist who claims to have seen higher than normal rates of hepatitis B amongst people who have travelled to lower cost countries for dental treatment.

One country was mentioned in particular (not India as it happens).

<comment><USER58> Your comment left out the single most important piece of information: the country in which the treatment took place. I have no plans, and thankfully no need, to go abroad for low-cost treatment of any sort, but someone reading your comment might, and the key fact you omitted might stop them making a horrible mistake.

<comment><USER57> I was tempted to mention it. But what I am writing is hearsay until such time as this doctor goes public with it, if he ever does that. If it's true it would cause a major controversy in the EU.

</comment></comment></comment><comment><USER59> heart surgery in China: $237.95 heart surgery in Mexico: $199 on Saturdays

WTF is the point of talking about is, such BS. Who here is willing to have their baby girl's heart surgery done in India vs best of the US here?

</comment><comment><USER60> I'd like to point out that the price difference is most likely to do with the marked conditions of the health care in general, and has nothing to do with the quality of the operation itself.

There is a big problem with health care in most countries that I've been living into for extended periods of time (France, Italy and to a lesser extent Germany).

Anything sorrounding "medical" and/or "health care" has a 10x-100x price blowup, for absolutely no reason. I'm not even speaking about surgery, I can start by phisiotherapy consumables, such as elastic bands. Elastic bands are used in phisical rehab. They are dirt cheap, usually, if you buy them inside a child play store. But behold, if you buy the _same_ stuff from "Thera Band", which is officially sold to hospitals and clinics, a couple of meters of the stuff will cost you 20-30 times more. I worked as an assistant in a phisical rehab clinic for several years, and this kind of bullshit is _amazing_ , because it goes for _everything_ (air balls, plastic rods for balancing excercises, and so on). The price inflation goes even higher with actual machines.

There is a machine which is called "Rehab 3xxxx" (produced by a clinic around here which I helped develop, so I won't disclose the details), which is just a linear actuator which moves _back and forth_. Literally, nothing more. There is an embedded controller which allows to tune the extension limits, and a couple of ABS plastic accessories that hold to the knee, wrist, etc.

The idea is just to move the articulation, and/or rotate it, over and over. You would think that there is something "fancy" about it, to name a few details which I _wished_ this machine had:

* force feedback to stop the motion (right now the machine will just twist your arm as configured, no matter the force) * speed regulation (who needs it? just one speed is good enough) * some sort of patient-id so that you don't need to reconfigure it each time

But not really. Like I said, this is just a dumb linear actuator, with incredibly cheap ABS plastic accessories and a fancy name. Price? 30k euros in the basic kit.

The funny part: for anything medical, you have to demonstrate that this machine is effective somehow. So we had a trial in an hospital, wrote an article about the effectiveness (or lack thereof) and did some paperwork. The idea is that you just have to demonstrate that it doesn't _hurt_. Of course, a physiotherapist will be twice as effective, but it's more expensive on an hourly basis, so that's why clinics love to buy the machine and just let patients sit on it.

I'm literally disgusted, but I can see everything around "medical" equipment having the same issues. All the economy surrounding hospitals, doctors and equipment is essentially broken, because there's essentially no competition, assured money (by the state in this case) and a lot of corruption going on within the clinics and medical companies (unfortunately).

edit: english.

<comment><USER6> What you describe sounds a lot like the problems the developed when supplying to government in general, whether it be IT, military, transport, etc. That said to me the US system sounds like it's so rigged that it has developed many of the same problems you encounter with government inflicted monopolies.

<comment><USER61> I wonder how many medical offices with a staff of 3 have a Cisco 3950 in the closet...

</comment></comment></comment><comment><USER62> Given that surgery costs are dominated by labor costs (surgeon plus support staff) and labor costs 20x more in the US than in India (see: [http://www.economicpopulist.org/content/china-and-india- real...](http://www.economicpopulist.org/content/china-and-india-really-are- cheap-labor-manufacturing)) is it any wonder that surgery is 10x more expensive in the US? If the only cost were labor it would be 20x!

</comment><comment><USER63> The situation in other Asian countries like India, Taiwan, or South Korea is nearly the same. There are still some obstables. A different environment and unknown results may be the major ones. People should try to calculate the overall outcome and costs and maybe come up with some good international insurance packages.

</comment><comment><USER54> One of the prerequisites for markets to work is that, both the parties should get into a transaction willingly. That premise somehow gets violated when it comes to healthcare. That is why there are too many market inefficiencies which are skewed towards hospitals and insurance companies.

</comment><comment><USER64> For anyone interested, I'll perform heart surgery for you in India for only $1200.

</comment><comment><USER65> I'm just curious to know the situation in countries like Russia and China, because many of my friends took their medical degree from those Countries. Is is just the education is cheaper or entire industry?

<comment><USER66> I am from India. I think one major cost factor is price of medicine. In India, you can get medicine at very low cost compared to the west. Salary and dollar conversion/PPP are also major cost factors. For instance, a urine test costs $1-$1.5 in India, urine culture is about $6, a USG scan is about $14. In USA, urine routine is $30, culture is $70 and USG is $750

</comment></comment><comment><USER67> India is just cheap and best :> I wonder it would be great if the medical facilities in india be improved considering the huge mass of population.

</comment><comment><USER68> Anything you can do, we can do cheaper, and better.

</comment><comment><USER69> Bloomberg is comparing apples and oranges, to the point of caricaturization. They are also link baiting with false statements.

First, the link bait: "The same procedure costs $106,385 at Ohio's Cleveland Clinic, according to data from the U.S. Centers for Medicare & Medicaid Services." Funny thing is they actually cite their data source, so I downloaded the Excel sheet and looked for myself. The $106,385 is the "Average Covered Charges" for "238 - MAJOR CARDIOVASC PROCEDURES W/O MCC" at Cleveland Clinic. If you read the definition of "Average Covered Charges", it is not the cost of the procedure. The _cost_ , aka "Average Total Payments" was actually $26,898. That's what medicare pays, including co-pays, deductibles.

I spent a few minutes browsing [http://my.clevelandclinic.org/](http://my.clevelandclinic.org/) \- the Ohio Cleveland Clinic has over 3,000 physicians and scientists, 1,700 residents and fellows in training, with 47 buildings on 167 acres. They helped _develop_ coronary bypass surgery in 1967.

Shetty (the "Henry Ford of heart surgery") is standing on the shoulders of giants, and as well he should. The Cleveland Clinic and Narayana Hrudayalaya coexist symbiotically, and I'm happy we have both in the world. Coronary bypass surgery has to be invented first at Cleveland Clinic before Shetty can put it on the assembly line.

If you have the time, read the Cleveland Clinic's 2012 Annual Report ([http://viewer.zmags.com/publication/71bd62a6#/71bd62a6/1](http://viewer.zmags.com/publication/71bd62a6#/71bd62a6/1)) and you can see what _they_ think they are doing differently to provide the best service, continue driving innovative research, support their local community, and reduce costs. Take a minute to appreciate the breadth of research that goes on in their facilities, in areas including high-performance computing, robotics, 3D printing...

Cleveland Clinic had $228m in Operating Income on $6.2b in Revenue in 2012. Their $6b in expenses are dominated by $3.5 billion in "salaries, wages, and benefits" which unfortunately is not broken down much further that I could find in the report. "Functionally" their expenses are $4.7b healthcare services, $450m on education and research, and $663m on G&A. I was disappointed to see their education and research expenses are less than their G&A, but it's hard to draw conclusions from such high-level data. It was interesting to note they have $1.6b of accumulated pension benefits, which are 68% funded.

Unfortunately there doesn't appear to be anything resembling a financial statement on [http://www.narayanahospitals.com/](http://www.narayanahospitals.com/).</comment>


Can I get faster off of Heroku? - <AUTHOR>

The question is: will I be see a speed bump by moving off of Heroku?
We're using Heroku.  It's great.  I love it.  We spend a few thousand a month on it, between instances and databases, and generally couldn't be happier.  However, we're scoping a new project that would require us to hit pretty aggressive latency targets -- sub 100ms.
Currently, we're a Rails 3 app processing between 80-90% of our requests sub 100ms, as measured by new-relic.  Given that we have to hit the latency target from the client's perspective, I'm going to fudge another 10% hit to that success rate (thus down to about 3/4 of requests).
Yes, there are occasional network blips on Heroku that can cause latency, but we're fine tying our success to Heroku's at least in the short term.
If we want to hit the 100ms latency target for 95% of requests, I see 3 options: a) Optimize on our current rails stack in Heroku b) Move to straight AWS, or other hosting provider c) Rebuild functionality into something I feel more confident could hit the latency target.  Probably Java.
a is obviously the prime candiate, but I've already picked off the low-hanging fruit.  c is probably most certainly the most likely to succeed, but also take the most work (most of the engineers today came from Java, so we don't have any Ruby->Java penalty).  But b is kind of a dark horse, where it could be good or it could be worse -- I don't know how to tell without trying it out and load testing, but then, that's basically just doing it and seeing if it was successful.
I'm trying to decide between them, or find a way to decide between them. Any advice? experience?
*The majority of our requests do not require us to render html. <comment><USER2> A dedicated server is probably your best bet, shared hosting solutions are always going to have contention.

But first, is there anyway you can measure where the time is spent in your application ? I know from profiling Java apps you often get great performance improvements from changing just a small amount of code.</comment>


A JavaScript Port of the 1986 Amiga Juggler Raytracer - <AUTHOR> http://home.comcast.net/~erniew/cghist/juggler_rt.html <comment><AUTHOR> For some context, this was the first raytracer that ran on any personal computer.

Some more context here: [http://home.comcast.net/~erniew/juggler.html](http://home.comcast.net/~erniew/juggler.html)

and a bit more here: [http://www.pouet.net/prod.php?which=10776](http://www.pouet.net/prod.php?which=10776)

The source code is refreshingly simple and easy to read: both the original C code and the ported JS code.

<comment><USER2> I trust you are accurate because of your username.

<comment><USER3> You do? I think I see blinking red bars around his username...

</comment></comment></comment><comment><USER4> The Juggler showed off the Amiga graphic abilities. It is what helped sell some of the 1986 and 1987 Amiga computers.

Before that it was a bouncing checkered beach ball. Other computers did their own bouncing ball, but the Amiga could multitask and had multiple bouncing beach balls, each program running on its own. I think you could have multiple jugglers as well.

<comment><USER3> A few years later 1992 "State of the Art", Spaceballs demo shows off Amiga 500 pretty well. That whole thing fits on 880 kB floppy and it's rendered realtime.

[https://www.youtube.com/watch?v=89wq5EoXy-0](https://www.youtube.com/watch?v=89wq5EoXy-0)

A year later same group released "9 Fingers", also running on Amiga 500.

[https://www.youtube.com/watch?v=PPoYzwib7JQ](https://www.youtube.com/watch?v=PPoYzwib7JQ)

<comment><USER5> Did those run on a stock Amiga 500?

<comment><AUTHOR> Yes, this ran on an 1987 Amiga 500 with the Commodore A501[1] 512K RAM expansion. This means:

      * 1MB RAM
      * 256K ROM
      * 7.16 MHz (yes, that's 0.007 GHz :)) Motorola 68000

plus a whole lot of custom chips [2]

There were different ways of expanding the Amiga RAM and the demo became so popular it was reverse engineered by a popular cracking group Skid Row[3,4]., patched and re-distributed

[1] [http://amiga.resource.cx/exp/a501](http://amiga.resource.cx/exp/a501)

[2] [http://en.wikipedia.org/wiki/Amiga_500](http://en.wikipedia.org/wiki/Amiga_500)

[3] [http://www.exotica.org.uk/wiki/Skid_Row_%28old%29](http://www.exotica.org.uk/wiki/Skid_Row_%28old%29)

[4] [https://www.youtube.com/watch?v=uqfcrViBGn8](https://www.youtube.com/watch?v=uqfcrViBGn8)

<comment><USER5> This says 50fps, so I assume it was the 7.09MHz version...

<comment><AUTHOR> Correct, just like with the Commodore 64, the CPU clock actually differed based on the graphics hardware output, which was back in the day adjusted for the household CRT TV sets.

The master clock crystal oscillator on the motherboard was set to be 2 clock cycles per pixel and other chips clocks were derived from that.

Hence the CPU was set to 1/4th of master clock, so the European PAL[1] machines (a 50fps TV standard) actually ran slightly slower than the American NTSC[2] machines (a 60fps TV standard with a smaller vertical resolution).

[1] [http://en.wikipedia.org/wiki/PAL](http://en.wikipedia.org/wiki/PAL)

[2] [http://en.wikipedia.org/wiki/NTSC](http://en.wikipedia.org/wiki/NTSC)

</comment></comment></comment></comment></comment></comment><comment><USER6> It's pretty cool to click on the link and be able to run a ray tracer on your phone. Maybe more exciting because you get the drama of it taking a couple seconds to render.

Ironic that compute has come so far yet real time movie quality graphics are still only a dream.

We have GPU based ray tracing, and if you stuff a 44u rack full of them it becomes more tolerable, but still nothing approaching 24fps for complex scenes and effects,

This has a lot to do with the content being more complex compared to say, what was done for a movie like Tron. But it's more than that. How many other problem domains could eat 5 orders of magnitude of performance increases and easily make use of it for everyday consumer applications? That still might not even be enough to get us out of the uncanny valley.

</comment><comment><USER7> Heh. I thought it was going to be animated.

</comment><comment><USER8> This has nothing to do with the Amiga, but shameless plug for a cool in- browser ray-tracer we made for a school project [http://camargo.github.io/tracejs/#/](http://camargo.github.io/tracejs/#/)

Rendering times become exponentially slower with more objects in the scene (100% native Javascript, hence 0 hardware acceleration) but it's fun to play with if you're in the mood!

<comment> david-given If you want the other extreme, these days you can do real-time raytracing entirely in an OpenGL shader:

[https://www.shadertoy.com/view/XdfXDB](https://www.shadertoy.com/view/XdfXDB)

(There's no geometry in that scene --- the shader is run for each pixel independently!)

</comment></comment><comment><USER9> It's interesting that they chose to port the source to JS by hand, rather than compiling the C to asm.js with emscripten. It'd probably have been easier, and the resulting code faster, if this approach was taken.

<comment><USER10> They should have just taken a still of the original and pasted it as a png. Would have been easier, and requires less CPU. But I don't think that was the point of the whole exercise.

</comment></comment><comment><USER11> Multithreaded ray tracing C# version: [https://github.com/wieslawsoltes/rt](https://github.com/wieslawsoltes/rt)

</comment><comment><USER12> Project Amiga Juggler: [http://meatfighter.com/juggler/](http://meatfighter.com/juggler/)

Step by step tutorial in Java.

</comment><comment><USER13> i'm surprised to see so much badness in the original code.

it kind of takes away from the rose tinted view i have of the past being dominated by awesome programmers who got the most out of the hardware...

<comment><USER14> For what it was aiming to do, I think it makes a lot of sense, albeit it might be a little bit too factored for the data(e.g. passing in the whole world to functions called only once).

You can kind of tell that this is more "proof of concept" than "artistic triumph" because the scene itself is relatively bland stuff, with its most impressive aspect today being that the juggler actually animates somewhat like a person. Everything else is just a straightforward demonstration of the Amiga's compute resources and display capability. Since the output was always going to be a single prerendered animation, deep optimization probably wouldn't be worth it.

<comment><USER13> i mean stuff like the wonky reflection code and checkerboard logic... its a bit 'special', even for a proof of concept.

its unexpected given the apparent intuition for rendering/geometry/maths from the simple, yet clever animation used.

</comment></comment></comment><comment><USER15> I wish he hadn't made so many modifications.</comment>


React Native vs. Expo - <AUTHOR> http://useful.ly/blog/react-native-vs-expo/ <comment><USER2> I'm react-native plugin developer, but still struggle to understand the value proposition of Expo. Or maybe proposition is OK, but real life experience is miles different. I think most projects very soon get to the point, where they need to be ejected from Expo, because of need of external react-native plugin.

<comment><AUTHOR> I see it more of a fast start to generate an MVP type of product because their are certainly still flaws in expo but the whole idea of not worrying about module updates breaking your app are huge. I personally use and like both but for different situations

</comment></comment><comment><USER3> A nice collection of often useful examples done in React Native [https://reactnativeexample.com/](https://reactnativeexample.com/)</comment>


Ways Docker Changed the Way Software Engineers Work in Past Half Decade - <AUTHOR> https://geshan.com.np/blog/2018/12/4-ways-docker-changed-the-way-software-engineers-work-in-past-half-decade/ <comment><USER2> Did it annoy anyone else that they say they say "10 years" instead of "a decade" and "half decade" instead of "5 years"

<comment><USER3> Year? Do you perhaps mean decidecade?

<comment><USER4> A millimillennium.</comment></comment></comment>


IPhone 5 to Get Aluminum Backing, Redesigned Antenna? - <AUTHOR> http://www.macrumors.com/2011/03/07/iphone-5-to-get-aluminum-backing-redesigned-antenna/ <comment><USER2> Ugh, I really hope this isnt true. I know it's all subjective, but I think the current iteration is the coolest looking one. I think Apple was pretty proud of it, I have a feeling they will stick to that design and just fix the antenna problems instead of going with another complete overhaul.

<comment><USER3> I know I'm quite the minority, but I still like the 3GS design more than the new one. Always thought the roundness was kinda neat. That said, that mockup looks sexy, hope it's true.

<comment><USER4> The 3GS felt really good in the hand. Ergonomically it worked better for me. The iPhone 4, in my opinion, looks much cooler, but doesn't fit as nicely in the hand.

<comment><USER5> Yes, the 'soapbar' design of the earlier iPhones fit your hand much nicer. While not exactly painful, the iPhone 4 edgyness actually hurts your hand a little. Also, it's way more slippery. And how much better the antenna design may be, I can get it to disconnect from my Airport Extreme 6 meters and a chalkboard-wood-and-rockwool wall away; just by holding it in a comfortable 'landscape' grip over the top of the iPhone.

</comment></comment></comment></comment><comment><USER6> Highly doubt it, looking at the photos it appears to be too similar to the original iPhone, and if you recall there were antenna issues related with the all aluminum casing. Apple isn't a backward thinking company.

<comment><USER7> Not to mention that the case looks horrible..white and aluminium??!

</comment></comment><comment><USER8> Sorry guys. This is not factual. If this is even a real prototype, which I doubt, Apple is notorious for not having one but many prototype designs. Furthermore, Apple and it's designers have nor would go backwards in their design evolution. There is no need to. Still furthermore, this would be the earliest design leak by Apple in 10 years, other than the iPhone 4. It doesn't make any sense. What does make sense is that a bunch of guys with nothing better to do on Saturday night would fantasize about what the next gen would look like then illustrate it then post it on the internets.

tl:dr... Fake.

</comment><comment><USER9> It is pure speculations. Anyone can make semi-educated guess of what Apple would do with the next iPhone.

Antenna redesign? If Apple wanted to make a hybrid GSM+CDMA iPhone, then the antenna has to be redesigned.

Aluminum backing? Instead of the glass back-plate in iPhone 4, Apple could replace it with Aluminum one. There's a replacement Aluminum back-plate for iPhone 4, sold by third party.

</comment><comment><USER10> That looks like the old iPodTouch before the most recent generation (and I wouldn't be surprised if it's an old prototype from then)</comment>


Earth's Final Sunset Predicted  - <AUTHOR> http://www.space.com/scienceastronomy/080226-vaporized-earth.html

<comment><USER2> I sure hope no one cares, when estimates vary by 1-2 billion years; no thanks.

</comment><comment><USER3> I sure hope I am dead by then.</comment>


Show HN: Review my startup idea – financial forecasting for small businesses - <AUTHOR>

HN,
I've founded www.investable.io creating a web app for small businesses who need a financial/operational forecast for the purpose of pitching to investors.
Right now I just have a prototype working and trying to get my first paying customers.
Was hoping to get some feedback from those of you who have used something like this before or have done work in the space.
Any feedback on my landing page or pricing would be hugely helpful. Right now I just have a basic forecasting tool so charging a flat fee, but looking to get into a monthly revenue model once I have some other functionality built in.
If any of you are interested in trying it out, just mention to me that you heard about it on HN and I'll hook you up with a discount. <comment><USER2> It's not clear to me whether you're building a financial model in Excel, which will then be automatically updated with actual data (for periods which have been completed), or whether Excel is just a way for you to gather the initial data.

You're solving a worthwhile problem, as most businesses could do with planning better and thinking more about the key drivers of cash flow.

If you are targeting businesses that are looking for investment, then presumably you'll need to output an Excel-based model that investors can inspect (for correctness) and play with (to test the impact of different assumptions). It sounds hard to automate that unless you create a bunch of templates for different types of business with different growth drivers and revenue/cost structures. You could probably build one which could be used by most SaaS businesses, for instance, and another for restaurants and cafes etc.

I've found that getting people to explain to you how their business will work is the hard part. Building the Excel model once you have complete answers is the easy bit. Updating it for an ongoing business, and integrating actuals alongside projections, is a little more tricky.

<comment><AUTHOR> Thanks Rahim,

Right now we're using Excel to gather the initial data, but we're working on building it out so that all of the data gathering happens in our web app. We're working on building a sort of 'wizard' interface similar to TurboTax etc. where it will ask questions to narrow down what information is needed.

Definitely getting the output formatted as something investors can play with and double check will be big for us. We're working on developing a method to generate an Excel-based model from the app, but that's definitely one of the more technical challenges we're facing right now.</comment></comment>