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She got similar chemo in two different states. Why were the bills so different?

AILSA CHANG, HOST:

It's time now for our September Bill of the Month. Dr. Elisabeth Rosenthal is senior contributing editor with our partner, KFF Health News. Hey, Dr. Rosenthal.

ELISABETH ROSENTHAL: Hi. Good to be back again.

CHANG: So who are we meeting today?

ROSENTHAL: Today we're meeting Emily and Jered Gebel. They were living in Juneau, Alaska, when Emily was diagnosed with breast cancer. And the Gebels were shocked when they saw how much it could cost to get treatment there. Now, this is a little different than our usual bills because this couple didn't have to pay an outrageous sum of money.

CHANG: OK.

ROSENTHAL: But the story does highlight how health care costs can vary widely depending on where you live in the country.

CHANG: Well, KFF Health News reporter Arielle Zionts has Emily and Jered's story.

ARIELLE ZIONTS: Emily Gebel was having trouble breastfeeding when she felt an unusual lump. She had some tests done. When she got the call with her diagnosis and learned she had breast cancer, Emily's 9-month-old was asleep in her arms.

EMILY GEBEL: And I remember I just sat there for probably at least half an hour or so and cried. And I called my husband and said, when are you going to be home?

ZIONTS: Gebel has several friends who've also had cancer and says all of them suggested she seek treatment out of town because they felt bigger cities would have higher-quality care. So Emily decided to have her surgery and chemo in Seattle. But traveling was hard.

E GEBEL: I wanted to be able to get it here in Juneau, of course, because it's very cumbersome to fly every single week just for a chemotherapy treatment.

ZIONTS: So after about a dozen trips, Emily switched her treatment to the hospital in Juneau, where she was living at the time. She recently got her first bill. It highlights the high price of health care in Alaska. Even common things were costlier. Benadryl was about 22 times more expensive. One of the most expensive drugs was more than three times the Seattle price. These medicines, plus all the other costs of chemo, added up to about $5,000 for one session. In Seattle, a session with a similar mix of drugs added up to about $1,600.

E GEBEL: When you're a patient dealing with a life-threatening illness, you wonder why there can't just be more of a focus on what's realistic for people. Many people go bankrupt paying for their cancer care, and that's not right.

ZIONTS: Those were the prices before insurance was applied. Emily had already met her out-of-pocket maximum for the year. That means her health insurance is expected to cover the entire cost of her treatment. Still, Emily and her husband, Jered, were horrified by the prices.

JERED GEBEL: Oh, my goodness. This has to be wrong, and I'm going to fight this.

ZIONTS: Jered knows what to look for because he's somewhat of a self-taught medical billing expert. He even used a day off from work to show up at the hospital, armed with spreadsheets, asking for an explanation. And he actually uncovered two billing errors. One time, he realized an estimate was too high.

J GEBEL: If I'm able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows? Maybe eventually, health care prices can come down.

ZIONTS: We asked the Alaska hospital about their prices. The chief financial officer, who no longer works there, says the hospital set its cost after looking at wholesale prices from manufacturers and how much other hospitals in the region charge. But he said their medical center also needed to account for high operating costs related to Juneau's remote location. The city is only accessible by boat or plane. He said that makes everything more expensive, from shipping medical supplies to flying in doctors.

CHANG: All right. That was Arielle Zionts with our partner KFF Health News. We are back now with Dr. Elisabeth Rosenthal. So what do you make of this? Can a hospital's remote location mean that cancer treatment would cost that much more?

ROSENTHAL: Sure. Juneau and Alaska's small population and remote location makes everything more expensive, including health care. One expert on Alaska's health costs said even all those factors don't explain why the charges in Alaska are just so very high.

CHANG: Oh, really? OK. So what else is going on here that might be causing higher prices?

ROSENTHAL: The first thing is that hospitals can basically charge whatever they want. Many states are experimenting with different ways to curb prices, and Alaska actually tried one that seems to have backfired. It's called the 80th percentile rule and was meant to limit the amount of money patients had to pay when they were treated by providers outside their health network. It says that insurers' payments is tied to the 80th percentile of what all doctors charge in the area. But since doctors in an area can charge a whole lot, it seems only to have made the problem worse and things more expensive.

CHANG: OK. Well, meanwhile, what can Alaskans or anyone living in a place with especially high health care prices do when they get an expensive bill?

ROSENTHAL: First, checking the prices at another health system is always worthwhile. More generally, always ask for an itemized bill, and make sure the billing codes match the services you were provided. As we just heard in this story about Emily and Jered, it can be helpful to raise those concerns during an in-person meeting if you can get one.

CHANG: Dr. Elisabeth Rosenthal, thank you again.

ROSENTHAL: Thank you for having me.

CHANG: And if you have a confusing or outrageous medical bill that you want us to review, please go to NPR's Shots blog and tell us all about it. Transcript provided by NPR, Copyright NPR.

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Arielle Zionts