Late last year, Ronmel Rangel, then 63, began to feel a familiar discomfort in his lower abdomen. Twenty-five years earlier, while living in his native Venezuela, he had undergone surgery to repair a hernia in the right side of his groin.
Now, the same pain was back, but on the left side.
This time, Rangel was in the United States and did not have health insurance. In 2019 she had moved to Portland, Maine, where one of her daughters lives.
As a permanent resident, you qualified to purchase health insurance through the Affordable Care Act (ACA) insurance marketplace. But she soon discovered that the premiums for someone her age were out of her budget. Although having health coverage was one of his priorities, he decided to go without insurance.
Instead, he signed up for a clinic. concierge medicinewhere patients pay between $70 and $110 a month for services that include unlimited doctor visits and minor procedures, such as sutures and biopsies.
But when he was diagnosed with a hernia, surgery became inevitable. Ben Hagopian, his primary care doctor, helped him come up with a list of hospitals and surgery centers to consider. Rangel has a doctorate in Administration, a career he studied while serving in the Venezuelan Navy. Armed with that knowledge and a natural curiosity, he began researching prices.
What he found might be difficult for the average patient to understand. But their efforts were worth it when the bill arrived.
The medical service
Rangel had an inguinal hernia, a condition that occurs when part of the contents of the abdomen protrude through a thin spot in the lower abdominal wall. It is a relatively common condition, especially among older adults.
In most cases, surgery is required to repair the muscle wall, and the procedure can be performed on an outpatient basis. There are three main approaches to repairing an inguinal hernia: open, laparoscopic, and robot-assisted surgery. Studies have shown that all three methods have equally low rates of hernia recurrence, and are safe and effective.
Rangel underwent open surgery, a technique doctors often prefer when dealing with recurrent hernias. He said that the operation lasted less than two hours and that he was able to walk out of the surgical center shortly after.
The invoice
$2,900: The flat fee Rangel ended up paying for her hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fees and anesthesia. He also said he spent about $1,800 to travel from his home in Maine to the surgery center, including plane tickets, meals and lodging for himself and his wife.
Since Rangel did not have health insurance, he had no protection against high costs. His only advantage was having time to find a reasonable price for his surgery.
His first stop was a nonprofit hospital near his home. He scheduled a consultation with a surgeon at MaineHealth, the state’s largest hospital system, and was quoted approximately $23,000 to repair his hernia through laparoscopic surgery.
“I wasn’t going to mortgage my life just to have surgery.”
Ronmel Rangel Patient
Laparoscopic surgeries typically cost more because surgeons use more advanced tools. Still, laparoscopic inguinal hernia repair costs, on average, almost twice as much in a hospital as it does in an outpatient surgery center for a Medicare-covered patient. The hospital pays $5,280 for the procedure.
I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off that debt,” said Rangel, who is now 64.
So he kept searching. He considered a surgical center in Oklahoma, where the procedure was much cheaper, but ultimately ruled out that option because it was too far away. She also explored the possibility of traveling to the Universidad de los Andes, in Santiago de Chile, where another of her daughters lives. There the surgery would have cost around $7,000, but when adding several thousand in travel expenses, the alternative no longer made sense from an economic point of view.
Gerard Anderson, a professor who studies health spending at the Johns Hopkins Bloomberg School of Public Health, explained that people without health insurance tend to be the hardest hit by huge price swings.
A closer look at any hospital bill helps understand why.
“Every hospital is different,” Anderson said, “but generally, about half of the total charge is for facility use,” an additional cost that hospitals charge to cover their operating expenses.
Anderson explained that hospitals tend to raise their prices much more than smaller medical centers.
Medical billing researchers point out that part of the price difference between hospitals and ambulatory surgery centers reflects the higher operating costs involved in running a hospital.
Hagopian, Rangel’s doctor, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain those high costs,” he said.
MaineHealth declined to comment to and referred questions about the cost of the hospital procedure to Jeffrey Austin, president of the Maine Hospital Association.
Austin explained that unlike surgery centers, hospitals must absorb the costs of services that generate economic losses, such as mental health care and care for patients covered by Medicaid. He added that the revenue generated by a health system’s large hospitals helps sustain other centers, improving access to health care.
Hospital prices, which can vary considerably, are also determined by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiating… or the total amount they will have to pay.
Anderson recalled that there are standardized rates for Medicare and Medicaid, but not for most private sector medical services. “In the private market, providers can charge pretty much whatever they want.”
The resolution
Rangel has another daughter in Argentina, a son in Venezuela and other relatives in Spain. But he decided to stop searching around the world for a better 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 and very well-coordinated system” accompanied him throughout the process.
“I received very professional and, at the same time, very humane attention,” said Rangel. As the surgeon had anticipated, he made a complete recovery in two weeks.
The surgery center charged him a flat fee for the hernia repair. Additional expenses for the two-day trip with his wife were plane tickets, transportation, meals and one night in a hotel.
In total, Rangel said he spent approximately $4,700.
Alan Kravitz, the surgeon who performed the operation, believes the price difference faced by uninsured patients compared to those with coverage is far from fair.
“In the predatory and strategic world of health care pricing in the United States, uninsured patients are typically charged far more than a provider would accept from Medicare or commercial insurance,” he said.
Kravitz then showed an estimate another patient had received for an inguinal hernia repair at another large hospital system: The estimate was $37,000.
The lesson
Without health insurance, many patients must negotiate on their own. “With the help of their primary care doctor, patients can research prices and compare options to avoid falling into medical debt,” explains Rangel.
However, that approach is much more viable when it comes to elective procedures for which there are several surgical options with comparable results.
Patients facing a medical emergency don’t have the time to shop around before seeking care, although many hospitals offer cash discounts or financial assistance programs for the uninsured.
Medical billing experts point out that those who do have time to shop around should look at more than just the cost. They also recommend reviewing the quality of hospitals and surgical centers by looking at their public ratings and opinions from other patients. Research shows that paying more does not necessarily mean receiving better care, although it is important to choose a provider with a good reputation.
Comparing healthcare prices can take time. But for those who need scheduled surgery, that effort can be worth it and, in some cases, save thousands of dollars.
“It was a learning experience for me,” Rangel said, “and I hope it is for other people, too.”
Bill of the Month is a collaborative investigation of and Well+Being from The Washington Post that analyzes and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills and has been cited in state legislatures, at the U.S. Capitol, and at the White House. Do you have a confusing or disproportionate medical bill that you want to share? Tell us your story!
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