美国国家公共电台 NPR--He and his wife both got cataract surgery. His bill was 20 times higher than hers

He and his wife both got cataract¹ surgery. His bill was 20 times higher than hers

Transcript²

Danilo Manimtim's vision was cloudy and blurred³ — and it was growing worse.

The 73-year-old retired⁴ orthopedic surgeon in Fresno, Calif., knew it was time for cataract surgery. "It's like car tires wearing out because you drive on them so much," he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly⁵, and Manimtim healed over the next few weeks.

Manimtim, who has a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem⁶ Blue Cross of California for outpatient care and is covered by Medicare for hospitalization.

Total Bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy⁷, and clinical laboratory services. Anthem paid $5,027 and initially⁸ billed Manimtim $4,057.

Service Providers: Saint Agnes Medical Center. It is part of Trinity Health, a nonprofit hospital system headquartered in Michigan with 88 hospitals and 125 urgent care centers across the country. The hospital system brought in nearly $20.2 billion in revenue for the most recent fiscal⁹ year.

Medical Service: Cataract surgery as an outpatient, involving anesthesia.

What Gives: Manimtim's big bill stems from a simple decision that turned out to be a pitfall¹⁰ in the nation's complicated health care system: He scheduled his surgery at a nearby hospital — a hospital that happened to charge about $7,000 more for the procedure than his insurer would pay.

Manimtim has proof that it could have been different right under his own roof: Four months later, his wife, Marilou Manimtim, 66, got the exact same procedure at an outpatient eye care surgical¹¹ center in Fresno called EYE-Q. It is a half-mile from Saint Agnes Medical Center but is not affiliated¹² with the hospital.

Both patients have the same insurance coverage¹³ through Anthem Blue Cross of California; they had identical cataract surgeries; and both providers were in Anthem's coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

"This is ridiculous, and it feels very unfair," Danilo Manimtim said. "How can it be so much more expensive than the surgical center? It's walking distance away, and if I would have gone there, I would have saved myself a lot of money."

Manimtim's insurance plan, via his employer, the California Public Employees' Retirement¹⁴ System, caps payment for outpatient cataract surgery at $2,000, according to Anthem. CalPERS instituted a "reference pricing" system in recent years, in which it determines a reasonable price for a high-quality procedure of that type in California. It then reimburses¹⁵ only up to that amount, encouraging patients to shop for treatment priced under the bar. For the cataract surgery itself, patients in Manimtim's plan are on the hook for any charges above $2,000 .

Even for hospital-based care, Saint Agnes' overall charges are high for cataract surgery, said Dr. Ira Weintraub, chief medical officer for WellRithms, which analyzes¹⁶ health care prices for employers. "The hospital charged three to four times the amount of what this surgery typically costs, which is around $3,000."

"Nobody gets $9,000 for cataract surgery," he added.

If Manimtim had opted¹⁷ for Medicare Part B, the part of the Medicare program that covers outpatient care, he likely would have been on the hook for only about $565, a Medicare cost comparison tool shows. Medicare pays a set amount for procedures regardless of where they are performed.

But like many older Americans who are still working, Manimtim chose not to sign up for that coverage, instead opting¹⁸ for his employer's plan because his monthly premium¹⁹ would be significantly cheaper.

Health care prices often have very little to do with the actual costs of providing the care and its quality — and patients often face the "double whammy" of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit advocacy group. Too often, patients are on their own to figure out how to use their plan's benefits, he said.

"You wonder what is the rationale for any of the prices in our health care system," Wright said.

Resolution: After inquiries²⁰ by KHN, Anthem contacted the hospital, Saint Agnes, seeking help for Manimtim. Although the doctor is responsible for requesting an exemption²¹ from CalPERS' $2,000 limit on payments for cataract surgery under Manimtim's plan, that didn't happen before his surgery. Anthem asked the hospital and doctor to consider the request post-surgery, said Anthem spokesperson Michael Bowman.

Saint Agnes spokesperson Kelley Sanchez told KHN that the hospital and provider later requested the exemption that would allow the insurer to pay more than the $2,000 limit and that it was ultimately approved by Anthem. That is expected to leave Manimtim with a much smaller coinsurance bill, around $750 — and get him off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

And that high payment, like all high payments, contributes to rising health insurance payments for all.

Sanchez said the hospital isn't in the price-gouging business but noted²² that hospitals generally have higher costs and tend to charge more than outpatient facilities.

"We never want to cause harm or create hardship for our patients, and that extends to our billing practices," Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. "Every patient's insurance plan is unique so it is their responsibility to understand their plan benefits," she wrote. "It's still complicated and we recognize that, and will continue to work toward greater price transparency."

The Takeaway: The bottom line for patients, experts say, is to be sure to read the fine print of insurance coverage plans to understand all out-of-pocket responsibilities, including premiums²³, deductibles, copays, and coinsurance. Also, a small number of large employers that self-insure are using reference pricing, putting caps on what they'll pay for common procedures. Shop around, and ask about prices on the front end if possible.

"People often focus on premiums because they are easy to compare, but premiums don't tell the full story, and this example illustrates²⁴ the trade-offs," said Tricia Neuman, a Medicare expert at KFF.

Anthem spokesperson Bowman urged patients to use the online Anthem "care finder" to compare patient costs and find a cheaper option if one is available. Had Manimtim done that, he might have seen that getting his cataract surgery at an outpatient surgical center would have been much cheaper. But the details of provider cost and insurance coverage can be idiosyncratic and are often not displayed in a patient-friendly manner. Manimtim did try to explore his benefits before the procedure, he said, but did not get a clear answer from the insurer or hospital.

Manimtim also had advice for consumers: If you receive a medical bill and don't understand the charges, don't pay right away. Instead, call your provider and insurer to ask about the charges and whether there are ways to lower your bill.

"People need to be more informed by the insurance companies and hospitals about what options they have, to prevent overbilling," Manimtim said. "A lot of people don't know this could happen to them."

Stephanie O'Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation²⁵ by KHN and NPR that dissects²⁶ and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

1 cataract   

n.大瀑布，奔流，洪水，白内障

参考例句：

• He is an elderly gentleman who had had a cataract operation.他是一位曾经动过白内障手术的老人。
• The way is blocked by the tall cataract.高悬的大瀑布挡住了去路。

2 transcript   

n.抄本，誊本，副本，肄业证书

参考例句：

• A transcript of the tapes was presented as evidence in court.一份录音带的文字本作为证据被呈交法庭。
• They wouldn't let me have a transcript of the interview.他们拒绝给我一份采访的文字整理稿。

3 blurred   

v.（使）变模糊( blur的过去式和过去分词 )；（使）难以区分；模模糊糊；迷离

参考例句：

• She suffered from dizziness and blurred vision. 她饱受头晕目眩之苦。
• Their lazy, blurred voices fell pleasantly on his ears. 他们那种慢吞吞、含糊不清的声音在他听起来却很悦耳。 来自《简明英汉词典》

4 retired   

adj.隐退的，退休的，退役的

参考例句：

• The old man retired to the country for rest.这位老人下乡休息去了。
• Many retired people take up gardening as a hobby.许多退休的人都以从事园艺为嗜好。

5 smoothly   

adv.平滑地，顺利地，流利地，流畅地

参考例句：

• The workmen are very cooperative,so the work goes on smoothly.工人们十分合作，所以工作进展顺利。
• Just change one or two words and the sentence will read smoothly.这句话只要动一两个字就顺了。

6 anthem   

n.圣歌，赞美诗，颂歌

参考例句：

• All those present were standing solemnly when the national anthem was played.奏国歌时全场肃立。
• As he stood on the winner's rostrum,he sang the words of the national anthem.他站在冠军领奖台上，唱起了国歌。

7 pharmacy   

n.药房，药剂学，制药业，配药业，一批备用药品

参考例句：

• She works at the pharmacy.她在药房工作。
• Modern pharmacy has solved the problem of sleeplessness.现代制药学已经解决了失眠问题。

8 initially   

adv.最初，开始

参考例句：

• The ban was initially opposed by the US.这一禁令首先遭到美国的反对。
• Feathers initially developed from insect scales.羽毛最初由昆虫的翅瓣演化而来。

9 fiscal   

adj.财政的，会计的，国库的，国库岁入的

参考例句：

• The increase of taxation is an important fiscal policy.增税是一项重要的财政政策。
• The government has two basic strategies of fiscal policy available.政府有两个可行的财政政策基本战略。

10 pitfall   

n.隐患，易犯的错误；陷阱，圈套

参考例句：

• The wolf was caught in a pitfall.那只狼是利用陷阱捉到的。
• The biggest potential pitfall may not be technical but budgetary.最大的潜在陷阱可能不是技术问题，而是预算。

11 surgical   

adj.外科的，外科医生的，手术上的

参考例句：

• He performs the surgical operations at the Red Cross Hospital.他在红十字会医院做外科手术。
• All surgical instruments must be sterilised before use.所有的外科手术器械在使用之前，必须消毒。

12 affiliated   

adj. 附属的, 有关连的

参考例句：

• The hospital is affiliated with the local university. 这家医院附属于当地大学。
• All affiliated members can vote. 所有隶属成员都有投票权。

13 coverage   

n.报导，保险范围，保险额，范围，覆盖

参考例句：

• There's little coverage of foreign news in the newspaper.报纸上几乎没有国外新闻报道。
• This is an insurance policy with extensive coverage.这是一项承保范围广泛的保险。

14 retirement   

n.退休，退职

参考例句：

• She wanted to enjoy her retirement without being beset by financial worries.她想享受退休生活而不必为金钱担忧。
• I have to put everything away for my retirement.我必须把一切都积蓄起来以便退休后用。

15 reimburses   

v.偿还，付还( reimburse的第三人称单数 )

参考例句：

• Reimburses the actual medical expenses due to an accidental injury or sickness. 赔偿因罹患疾病或意外事故，而导致的实际医药费用。 来自互联网
• ACE reimburses the insured's loss under policy term. ACE依保单承保责任补偿被保险人之损失。 来自互联网

16 analyzes   

v.分析( analyze的第三人称单数 )；分解；解释；对…进行心理分析

参考例句：

• This approach analyzes management by studying experience usually through cases. 这个学派通常从实例获得经验，用以分析管理。 来自辞典例句
• The econometrician analyzes statistical data. 经济计量学者要分析统计材料。 来自辞典例句

17 opted   

v.选择，挑选( opt的过去式和过去分词 )

参考例句：

• She was co-opted onto the board. 她获增选为董事会成员。
• After graduating she opted for a career in music. 毕业后她选择了从事音乐工作。

18 opting   

v.选择，挑选( opt的现在分词 )

参考例句：

• What courses are most students opting for? 多数学生选什么课程？ 来自《简明英汉词典》
• Wells doesn't rule out opting out and then re-signing with Houston. 威尔斯没有排除跳出合同再与火箭重签的可能。 来自互联网

19 premium   

n.加付款；赠品；adj.高级的；售价高的

参考例句：

• You have to pay a premium for express delivery.寄快递你得付额外费用。
• Fresh water was at a premium after the reservoir was contaminated.在水库被污染之后，清水便因稀而贵了。

20 inquiries   

n.调查( inquiry的名词复数 )；疑问；探究；打听

参考例句：

• He was released on bail pending further inquiries. 他获得保释，等候进一步调查。
• I have failed to reach them by postal inquiries. 我未能通过邮政查询与他们取得联系。 来自《现代汉英综合大词典》

21 exemption   

n.豁免，免税额，免除

参考例句：

• You may be able to apply for exemption from local taxes.你可能符合资格申请免除地方税。
• These goods are subject to exemption from tax.这些货物可以免税。

22 noted   

adj.著名的，知名的

参考例句：

• The local hotel is noted for its good table.当地的那家酒店以餐食精美而著称。
• Jim is noted for arriving late for work.吉姆上班迟到出了名。

23 premiums   

n.费用( premium的名词复数 )；保险费；额外费用；（商品定价、贷款利息等以外的）加价

参考例句：

• He paid premiums on his life insurance last year. 他去年付了人寿保险费。 来自《现代英汉综合大词典》
• Moves are afoot to increase car insurance premiums. 现正在酝酿提高汽车的保险费。 来自《简明英汉词典》

24 illustrates   

给…加插图( illustrate的第三人称单数 )； 说明； 表明； （用示例、图画等）说明

参考例句：

• This historical novel illustrates the breaking up of feudal society in microcosm. 这部历史小说是走向崩溃的封建社会的缩影。
• Alfred Adler, a famous doctor, had an experience which illustrates this. 阿尔弗莱德 - 阿德勒是一位著名的医生，他有过可以说明这点的经历。 来自中级百科部分

25 investigation   

n.调查，调查研究

参考例句：

• In an investigation,a new fact became known, which told against him.在调查中新发现了一件对他不利的事实。
• He drew the conclusion by building on his own investigation.他根据自己的调查研究作出结论。

26 dissects   

v.解剖（动物等）( dissect的第三人称单数 )；仔细分析或研究

参考例句：

• Meltzer dissects the penile skin free of the underlying erectile tissue. Meltzer将阴茎表皮与其下的勃起组织分割。 来自互联网
• This paper dissects the process to analyse arsenic in test method and operative skills. 本文从实验方法、操作技巧等方面剖析了砷测定方法的机理。 来自互联网