Late last year, 63-year-old Ronmel Rangel began feeling a familiar discomfort in his lower abdomen. Twenty-five years ago, while living in his native Venezuela, he had surgery to repair a hernia on the right side of his waist.
Now, the same pain was back – on the left side.
This time, Rangel was in the US and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.
As a green-card holder, he was eligible to purchase health insurance through the Affordable Care Act Marketplace. But he soon realized that the premium for someone his age was out of his budget. He decided to live without insurance even though it was a priority for him.
Instead, Rangel signed up for a plan at a concierge practice, where patients pay at least $70 a month for services that include unlimited office visits and minor procedures like stitches and biopsies.
But when Rangel was diagnosed with a hernia, surgery became inevitable. His primary care physician, Ben Hagopian, helped him compile a list of hospitals and surgery centers to consider. Rangel has a PhD in Management, a field he pursued while serving in the Venezuelan Navy. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.
His hard work paid off when the bill arrived.
medical service
Rangel had what is called a inguinal herniaWhich occurs when stomach contents leak out through a weak spot in the lower abdominal wall. This condition is relatively common, especially in older adults.
In most cases, surgery is required to repair the muscle wall and can be as an outpatient procedure. There are three main surgical approaches to repair inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have equally low hernia recurrence rates and are safe and effective.
Rangel performed an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours and he walked out of the surgical center shortly after.
Bill
$2,900: Rangel eventually paid the flat rate for her hernia repair at an outpatient surgery center in Maryland, which included the surgeon’s fee and anesthesia. He said he paid about $1,800 to travel from his home in Maine to the surgery center, which included airfare, meals and lodging for him and his wife.
Billing Problem: No Insurance – But Time to Shop
Since Rangel did not have insurance, he had no protection against high costs – except time and the ability to shop around for his procedure at an acceptable price.
Rangel’s first stop was a non-profit hospital near home. He scheduled a consultation with a surgeon at MaineHealth, the state’s largest health system, and received an estimate that repairing his hernia laparoscopically would cost about $23,000.
Laparoscopic procedures generally cost more because surgeons use more advanced equipment. Nevertheless, the average laparoscopic inguinal hernia repair costs about twice as much in a hospital as it does in an ambulatory surgery center for a single patient. covered by medicareJoe pays $5,280 for the hospital-based option.
“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the loan,” said Rangel, now 64.
So, he kept shopping. He considered a surgical center in Oklahoma that was much cheaper, but he ultimately rejected it because it was too far. He also traveled to the Universidad de los Andes in Santiago, Chile, where another daughter lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.
Patients without health insurance are often hardest hit by wide price variations, said Gerard Anderson, a professor who analyzes health care spending at the Johns Hopkins Bloomberg School of Public Health.
A close look at any hospital bill helps explain why. “Every hospital is different,” he said, “but typically about half of the total charge is a facility fee,” a fee added to hospital care to help cover overhead costs.
Anderson said hospitals often set much higher prices than smaller facilities.
Medical billing researchers say the price difference between hospitals and ambulatory surgery centers partly reflects the higher overhead costs of hospital operations.
Hagopian, Rangel’s physician, acknowledged that hospitals have high administrative costs. “But that doesn’t explain the high costs.”
MaineHealth declined to comment to KFF Health News, and referred questions about the cost of the hospital-based procedure to Jeffrey Austin, president of the Maine Hospital Association.
Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services such as behavioral health care and care for Medicaid patients. He said the revenue generated by larger hospitals supports other facilities in the health system, thereby improving access to care.
Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become a starting point for negotiation – or the full amount owed.
Anderson said standardized payment rates exist for Medicare and Medicaid, but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”
Resolution
Rangel has another daughter in Argentina, a son in Venezuela and other family in Spain. But he decided to stop looking around the world for a good price, because he finally found what he was looking for in Maryland.
In April, he traveled to the Affordable Hernia Surgery Center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.
“I received professional and very humane care,” Rangel said. He said that, as his surgeon had predicted, he made a full recovery within two weeks.
The surgery center charged Rangel a fixed fee for his hernia repair. Additional travel expenses for a two-day trip with his wife included airline tickets, transportation, meals, and a night in a hotel.
Rangel said he paid a total of about $4,700.
Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared to insured patients isn’t fair. “In the predatory and strategic world of American health care pricing, uninsured patients are typically charged more than Medicare or commercial insurance will allow providers to accept.”
Kravitz then pulled an estimate that another patient had received from a different large health system for an inguinal hernia repair. Price: $37,000.
takeaway
Without insurance, many patients must negotiate alone.
“With the help of their primary physicians, patients can find out prices and compare their options to avoid falling into medical debt,” Rangel said.
However, this approach is most viable for elective procedures, with many surgical options providing comparable results.
Patients experiencing medical emergencies do not have the luxury of comparing prices before seeking care, although many hospitals offer cash-payment discounts or charity care for those without insurance.
Billing analysts say patients who have time to make a purchase should look beyond just cost. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. Research has found Higher prices do not necessarily translate into better quality of care, but it is also important to select a reputable care provider.
Comparison shopping for medical care can take time. But for patients facing elective procedures, the effort can be successful – sometimes saving thousands of dollars.
“It was a learning experience for me and I hope it will be for other people too,” Rangel said.
Bill of the Month is a crowdsourced investigation by KFF Health News Washington Post Welfare Who analyzes and interprets medical bills. Since 2018, the series has helped many patients and readers reduce their medical bills, and has been quoted in statehouses, the US Capitol, and the White House. Do you have a confusing or embarrassing medical bill you want to share? Tell us about it!
