Despite getting the same cataract surgery under the same insurance as his wife, a patient was charged almost $4,000 more—a situation that underscores the "double whammy" of high prices and complex benefits faced by many patients, Angela Hart writes for Kaiser Health News.

Infographic: The patient financial journey

The same surgery, but drastically different costs

In 2021, Danilo Manimtim, a 73-year-old retired orthopedic surgeon, noticed his vision growing cloudy and blurry—a sign that he likely needed cataract surgery. "It's like car tires wearing out because you drive on them so much," he said.

In December, he went to the outpatient department of Saint Agnes Medical Center (SAMC) for the routine procedure, which went smoothly. After he healed, Manimtim, who evaluates disability claims for the state of California and regularly tracks his health benefits, calculated what his out-of-pocket cost would be for the surgery.

Since he had already met his deductible for the year, Manimtim estimated that his coinsurance would be around $750 for the surgery. However, when his bill arrived, the total charge for the surgery, anesthesia, medical supplies, and other services was $9,084, of which his portion was $4,057.

Later, Manimtim's wife received the same surgery, but at an outpatient eye care surgical center called EYE-Q, which is only half a mile from SAMC. This time, the out-of-pocket cost was only $204—even though both Manimtim and his wife had received the same surgery and have the same insurance coverage.

"This is ridiculous, and it feels very unfair," 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."

The 'double whammy' of high costs and complex benefits

Currently, Manimtim's insurance plan through his employer, the California Public Employees' Retirement System (CalPERS), limits the payment for outpatient cataract surgery at $2,000. This price cap, along with the hospital's high charge for the surgery, ultimately left Manimtim with a significantly higher out-of-pocket cost than he expected.

According to Ira Weintraub, CMO at WellRithms, a company that analyzes health care prices for employers, the cost of Manimtim's cataract surgery was quite high compared with what hospitals usually charge.

Anthony Wright, executive director of the nonprofit advocacy group Health Access California, said patients often face a "double whammy" of high prices and complex benefits, often making it difficult for them to discern the true costs of the care they receive.

"You wonder what is the rationale for any of the prices in our health care system," Wright said, noting that health care prices typically have little to do with the actual cost of care or its quality.

How the high bill was resolved

After Kaiser Health News inquired about Manimtim's situation, his insurer, Anthem Blue Cross of California reached out to SAMC to see if it would request an exemption to CalPERS' limit on cataract surgeries.

According to Kelley Sanchez, an SAMC spokesperson, the hospital requested the exemption, and Anthem later approved it, allowing them to pay more than the $2,000 limit. Manimtim is now expected to have a much smaller coinsurance bill of about $750—in line of what he originally estimated.

In a statement, Sanchez said SAMC is not trying to price gouge its patients but noted that hospitals usually have higher costs and charge more than outpatient facilities. "We never want to cause harm or create hardship for our patients, and that extends to our billing practices," she said.

In addition, Sanchez said SAMC has financial assistance programs for its patients and encourages them to ask questions about the potential costs before seeking care. "Every patient's insurance plan is unique so it is their responsibility to understand their plan benefits," she said. "It's still complicated and we recognize that, and will continue to work toward greater price transparency." (Hart, Kaiser Health News, 6/27)