Michelle Nichols had lived in pain since a childhood injury damaged her left knee.
It just got worse over the years. When the question on the doctors form asked, How many steps can you take without pain? my answer was zero. It choked me up. I had never thought about it like that. I just pushed through.
She needed a knee replacement, doctors told her. But she didnt have health insurance.
I had to put it off until I got health insurance. It was always, You want insurance or do you want to eat?
For patients, navigating the health care system and understanding medical costs can be difficult.
In April, she finally had her left knee replaced at Kansas Surgery and Recovery Center after signing up for health insurance on the new online marketplace that was created as part of the Affordable Care Act, which left her with mixed feelings.
Im not a cheerleader of Obamacare. There are other ways to do it, said Nichols, 51. Part of me is angry it was forced upon me, but at same time, Ive gotten my knee replacement.
Nichols had a lot of experience with medical bills in the past, raising three children, but her most recent experience held some surprises.
I was surprised at how much having insurance adjusted the amount billed, she said. The bill from the surgeon for knee (replacement) was $4,451. Then we filed the claim with insurance, and the amount was adjusted, reduced, to $2,107. Nearly half.
Nichols experience isnt that different from millions of American consumers who have found that the cost of health care services can vary widely depending on such factors as: whether you have insurance, the kind of insurance you have, who does the procedure, your geographic location and whether there are complications.
The Eagle asked local residents who had knee replacements to share information about their bills and experiences to study the differences in the amounts billed and the amounts paid for a relatively common procedure.
Despite having the same procedure as Nichols in the past year, Mary Jane Furches, a retired teacher, and Kathy McColpin, who works at a call center, were billed different amounts by the surgeons who performed their knee replacements.
Furches had her knee replacement at Wesley Medical Center in January.
She doesnt know the total bill yet, but the physician charged $3,677 for the surgery. Medicare paid $1,049 of that. There was an adjustment of about $2,600, and she is left to pay about $500.
Im still getting statements, she said. If I hadnt had Medicare, I dont think there would have been any way I could have had it done.
McColpin had both knees replaced at Kansas Spine Hospital at the end of last year: One in October and the other in December. Bone spurs were causing her pain every time she walked. She tried cortisone shots and a brace, but nothing worked.
She had both knees done within a couple of months so that both surgeries would be covered by her yearly deductible of $2,000. The surgeon fee for her right knee was $4,000, and she was billed another $1,595 for an assistant surgeon, but her insurance is covering most of the cost after the deductible.
Those surgeons bills are just a fraction of the overall cost of the procedure.
You can try to prepare ahead of time. Whats this going to cost? Whats my part? And then you get a bill from the anesthesiologist, a bill from the hospital, a bill from the doctor and then youve got rehab. There are all of these different bills and you cant seem to get a grasp of what the whole number is, McColpin said.
According to Healthcare Bluebook, the fair price or the typical amount for a total knee replacement in the Wichita area is $20,836, but the amount a person actually pays out of pocket will vary.
Typically, patients without insurance will be charged higher rates because insurance companies and government programs such as Medicare can negotiate lower rates with providers.
In the past few years, the push for more transparency in medical charges has gained traction.
Part of the reason is the continuing increase in health care costs, and part may be that the discussion over health care laws has brought new attention to the disparity in what different providers can charge for the same procedure.
People need to know that health care doesnt really cost that much to provide. What theyre being charged is another matter altogether, said Keith Smith, an anesthesiologist, medical director and cofounder at the Surgery Center of Oklahoma in Oklahoma City.
The center has listed prices for procedures on its website since 2009.
The center lists a $19,400 price tag for a knee replacement at a facility next door. The price includes the surgeon, anesthesiologist and facility fees in one price.
We are fans of the free market, Smith said. Our thought was that the health care industry could use competition and without transparent pricing, you cant have competition.
Patients from all 50 states have traveled to the center to get care as a sort of medical tourism, he said. The top two states from which the clinic gets patients from outside of Oklahoma are Alaska and Wisconsin.
Weve started a deflationary price war even outside of here, he said. Many patients are holding up our pricing as a reference point and demanding local hospitals match it or theyll travel.
While the center requires full payment at the time of service and does not accept insurance, some patients with insurance are able to file claims with their insurance companies afterward to help offset out-of-pocket costs.
The center has created the Free Market Medical Association, which has grown to five hospitals and 12 surgery centers across the U.S. that have the same model, he said.
The cronies and mainstream players in health care are not big fans of what were doing, Smith said. The free market is extremely powerful and often a deflationary tool and huge health care systems want no part of it.
In 2007, radiologist Jeff Rice founded Healthcare Bluebook, which works with about 20 health plans and hundreds of employers to help patients understand how much different procedures cost around the country.
The majority of patients dont know theres a really large price range, Rice said. If you think about buying gas, it might vary from $3.50 a gallon in one state to $3.60 a gallon in another. But what if it was $3 in one and $18 in another? Thats whats going on in health care.
The most important thing for patients to do is to understand how much care should cost and ask the provider before they get the care how much they will pay, Rice said.
According to an employer health benefits survey conducted by Kaiser Family Foundation, 23 percent of employers offer high deductible health plans with a savings option to employees, which is defined as a deductible of at least $1,000 for a single person.
The survey showed that more people are enrolling in these high deductible plans: 23 percent in 2013, 19 percent in 2012, 17 percent in 2011, 13 percent in 2010 and 8 percent in 2009.
Since patients are starting to share more of the cost, theyre much more engaged in trying to understand the costs and be more conscious in how to get and use care, Rice said.
Matt Leary, chief financial officer for Wesley Medical Center, agrees.
I think its great how active consumers are getting, specifically in health care. Consumers have always been very astute at going to buy a TV or fridge or microwave. Weve always had consumer reports to make sure youre getting the best value for the dollar, but in health care, its been like a black hole, Leary said.
We absolutely see that trend is changing ... the Affordable Care Act is really driving that consumerism in health care, which I think is great.
Understanding the code
Whenever an insured patient has a procedure, the cost is determined by negotiated prices between the providers, the facility and the insurance companies.
Facilities also have charge masters a master list of all the services a facility provides, said Carol Abou-Faissal, charge description master systems manager for Via Christi Health.
The charge master includes all of the medical codes the hospital uses to keep track and bill payers for different procedures. There are about 14,000 line items for Via Christi hospitals, Abou-Faissal said.
For example, a knee replacement at Via Christi (medical code: 27447) is estimated to cost between $36,192 and $54,839, with a median price of $45,953 and an average length of stay between two and four days, according to Via Christi.
The price includes the hospital stay, time using the operating room and the implant, but not physician, surgeon, radiologist, pathologist or anesthesiologist fees.
The charge master pricing is reviewed annually through Via Christis corporate finance division.
Via Christi provides a price line where patients can call to get an estimate for a procedure ahead of time, said Sheila Hale, director of revenue cycle for Via Christi Health. But the charge master itself is proprietary information, she said.
Susan Brown had her knee replacement at Wesley Medical Center last August.
Its extremely painful, she said. The first week I felt like that Klingon on Star Trek that this would be a good day to die. But God wouldnt let me die, he had me go through the pain. Its like childbirth. Theres nothing you can do but go through it.
Her bill from Wesley totaled $49,844. The biggest charges included:
• Three-day room stay: $4,689
• Drugs: $5,800
• Medical supplies: $2,266
• Implant: $8,607
• X-rays and lab: $2,021
• Operating room services: $21,011
• Anesthesia: $1,208
• Physical therapy: $3,196
• Recovery room: $972
People also should be aware of what their insurance plan will cover and their out of pocket expenses before elective procedures, Hale said.
For the uninsured, medical costs are often greater than for those with insurance.
At Via Christi, Hale said self-pay patients get a 15 percent discount for physician services and a 55 percent discount on hospital services. If patients still cant afford to pay, they can meet with financial counselors to see if they qualify for charity care up to 100 percent of the bill, she said.
Wesley Medical Center also has a charity care plan.
While cost is one component of finding medical care, physicians say patients should also look at quality.
Cost isnt everything, says orthopedic surgeon John Schurman, medical director for orthopedics at Via Christi.
Ive yet to find a patient to say Can you give me the cheapest knee you can? They want a knee that works, they want a good outcome, good safety. Cost is a factor, but thats not all of it.