Sherry Young just wanted to be able to walk without pain.
About three years ago, she began to experience sharp pain in her left foot. Her big toe had become crooked and constantly rubbed up against the adjacent toe, making it painful to run, walk or even stand. "I could not walk without intense pain unless I had a pad underneath my toes for cushioning," Young said.
An orthopedic surgeon told her that he could fix her problem for good. "He thought my foot was hitting the ground too hard and causing pain," said Young. "That's what he was trying to correct."
Though Young had had several orthopedic surgeries, she had always had good insurance and never scrutinized her bills.
At the time of her foot surgery, Young of course knew nothing about hospital charges for surgical screws, medical saws and other hardware used in the operating room.
Then the bill came.
Patient: Sherry Young, 57, a retired librarian on disability and a mother of two in Lawton, Okla.
Total bill: $115,527 for a three-day hospital stay, including $15,076 for four tiny screws — measuring 2.8 millimeters wide and no more than 14 millimeters long — placed in the two middle toes of her left foot.
Service provider: OU Medical Center, located at the University of Oklahoma Health Science Center in Oklahoma City
Medical treatment: Young underwent two operations on the same day in June 2017. One surgeon addressed an injury in Young's shoulder, caused by arthritis and overuse. A second surgeon performed several procedures on her foot, including removing a bone spur. To better align Young's middle toes, the doctor removed a slice of bone from the center of each toe, and then reconnected the two ends with surgical screws made by Arthrex, a medical device manufacturer based in Naples, Fla.
What gives: Two weeks after surgery, Young received a letter from her insurance plan, BlueCross BlueShield of Oklahoma, stating that it had not approved her hospital stay. Staying overnight was not "medically necessary," according to the letter, because foot and shoulder surgery are typically performed as outpatient procedures.
The letter "put me in a panic," said Young, who was suddenly worried that she would have to pay the entire $115,000 bill herself. That's about how much her home is worth, and five times her annual income.
Faced with the astronomical cost, Young asked for an itemized copy of her bill and began checking every charge.
She was floored by the price of the screws, each of which cost more than a high-end computer.
"Unless the metal [was] mined on an asteroid, I do not know why it should cost that amount," Young said.
She repeatedly asked officials at OU Medical Center for part numbers for the screws, so she could find out how much they cost the hospital. Hospital officials never provided the information, Young said.
John Schmieding, senior vice president and general counsel for Arthrex, declined to tell Kaiser Health News exactly how much his company charges hospitals for the type of screws implanted in Young's foot. But he did offer ballpark figures: "Our sale price for screws used in foot and ankle procedures would be below $300 per screw, with the most expensive around $1,000."
As for what the hospital charges, Schmieding said, "We do not direct or control how a facility bills for their procedure." Based on the numbers Schmieding provided, the hospital markup on Young's screws could range from roughly 275 percent to upwards of 1,150 percent.
"It's mind-boggling," said Dr. James Rickert, an orthopedic surgeon in Bedford, Ind., and president of the Society for Patient Centered Orthopedics, which advocates for affordable health care. "We are talking about little pieces of metal."
Yet such steep markups are common at hospitals, said Rickert, who was not involved in Young's care.
Clearly, the screws used in Young's surgery are more sophisticated than those sold at the local hardware store. Many of the screws in Arthrex's online catalog are made of titanium, which is popular for surgery because it's strong and durable. The screws are also hollow, designed to fit over a guidewire so that doctors can place them in precisely the right place.
Surgical device manufacturers also must comply with strict regulations, said Steve Lichtenthal, vice president of business development at the Orthopaedic Implant Co., based in Reno, Nev., which makes surgical supplies.
But even the fanciest screw is still pretty simple, Lichtenthal said. Tiny screws cost only about $30 to manufacture, and the technology hasn't changed much in decades, he said. About half the cost of a surgical implant goes toward paying sales and marketing staff, who develop close relationships with doctors and sometimes even attend surgery, Lichtenthal said.
Screws weren't the only expensive devices figuring into Young's bill. A drill bit, used for making holes in bone, carried a charge of $4,265; a tool for removing and cauterizing tissue was $5,047; a saw blade, $619.
While screws can be used only once, there's no reason that other surgical equipment, such as saw blades, should be disposable, Rickert said. Hospitals routinely sterilize tools such as scalpels and scissors, then use them again.
A hospital spokesman declined to comment on the specifics of Young's bill, as did the surgeon who operated on her foot.
OU Medical Center issued a statement that said: "OU Medical Center provides the highest-quality patient care. We are focused on acquiring the latest tools, treatments and technology, while diligently making sure we have the resources to maintain this commitment our patients deserve. We strive to keep costs down and focus investment on where it really matters — our patients."
In the statement, OU Medical Center said few patients pay the full price. Instead, insurance companies typically negotiate discounts with hospitals, allowing them to pay less than the amount on the list of charges.
Yet, as Young learned, people who are uninsured — or whose insurance plan refuses to pay — get no discount.
Resolution: Young is now off the hook. In a statement in response to a reporter's questions, BlueCross BlueShield of Oklahoma said it never actually denied Young's insurance claim but simply needed "additional information from the provider in order to process it correctly."
According to Young's most recent billing statement from OU Medical Center, she does not owe anything for her hospital stay. However, her latest statement from the hospital includes a $413 charge for an "appeal denied."
Surgery relieved the chronic pain in her shoulder and alleviated some but not all of the pain in her foot, Young said.
The takeaway: Companies can charge big prices for small surgical supplies, and hospitals can mark them up at will.
If you want to know exactly why your bill is so high, ask for an itemized list of charges. Since patients have no ability to shop around for different screws before the surgery, it's important to complain loudly to the hospital, your insurer and your employer if you see charges that seem outrageous.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. You can follow Liz Szabo on Twitter: @LizSzabo.
Jane Greenhalgh produced and edited the interview with Elisabeth Rosenthal for broadcast. Jackie Fortier from StateImpact Oklahoma reported from Lawton, Okla. Member station KGOU is part of StateImpact Oklahoma, a multistation reporting collaboration. KGOU is owned by the University of Oklahoma, which also owns and operates OU Medical Center.
DAVID GREENE, HOST:
If you've ever read an itemized medical bill, you might have noticed that small things can come with these ridiculously high prices. Every month, NPR with Kaiser Health News has been taking a close look at some of these bills, and I sat down with Kaiser Health News Editor-in-Chief Dr. Elisabeth Rosenthal.
Thanks for coming back.
ELISABETH ROSENTHAL: Oh, thanks for having me.
GREENE: All right, so we've been asking people to send us their medical bills, and you've been analyzing them. It sounds like a lot of it's been eye-popping. What have you been finding?
ROSENTHAL: Yeah, our bar is pretty high. We started off with a $17,000 bill for a urine test.
GREENE: Oh, my God.
ROSENTHAL: Then we went to two scans, one that cost 200, one the cost 9,000 - same scan, same city, just weeks apart.
GREENE: Different prices.
ROSENTHAL: Different prices. So this month, we're moving onto a new outrage, and it's about four little screws that a woman in Oklahoma got during toe surgery that ended up costing $15,000.
GREENE: Fifteen thousand dollars for four screws - I mean, those must be some screws. Well, we're going to hear her story here. Sherry Young, 57 years old - she lives in Lawton, Okla. And we sent a reporter named Jackie Fortier with StateImpact Oklahoma to hear her story firsthand.
JACKIE FORTIER, BYLINE: Hi.
SHERRY YOUNG: Hi. Nice to meet you. I'm Sherry.
FORTIER: I'm Jackie. Thank you so much for having me.
All Sherry Young wanted was to live without pain. She's had osteoarthritis for years.
YOUNG: I have arthritis in multiple areas of my body. And I was having sharp, stabbing pains in two different parts of my shoulder, and then I was having pain walking on the bottom of my foot.
FORTIER: She and her doctors came up with a plan - have two surgeries on the same day, one on her foot and one on her shoulder, both at the University of Oklahoma Medical Center in Oklahoma City. Due to her arthritis, she'd had surgeries before but had never really scrutinized the bill.
YOUNG: The insurance company paid their part of it, and my - I paid my part. I didn't pay much attention to it.
FORTIER: She was in the hospital for three days, and the surgeries were a success. But a few days later, back home recuperating, Young went to the mailbox.
YOUNG: Blue Cross sent me a letter saying that the surgery costs were denied because I had been put into the hospital. And the bill for all of it was about a $115,000.
FORTIER: Her insurance company had only approved an outpatient procedure, and so suddenly, Young found herself on the hook for the cost of the hospital stay and both the surgeries.
YOUNG: Well, I was shocked. I was still trying to recover from my surgery. I had my shoulder in a sling, and my foot was in a boot. So I started thinking about what it would do to me if I had a $115,000 debt that I would have to deal with for years and years.
FORTIER: With a bill about five times her annual income and more than the cost of her house, the retired university librarian started asking questions
YOUNG: I asked for an itemized bill because then I was extremely interested in why all of that added up to $115,000.
FORTIER: When the itemized bill arrived, she was stunned. One charge stood out - $15,000 for four tiny screws that were used to hold the bones of her foot together.
YOUNG: Unless the metal the screws are made of was mined on an asteroid, I don't know why tiny pieces of equipment should cost over $3,000 each.
FORTIER: The screws weren't the only shock - a drill bit for $2,000 dollars; a saw blade for more than 600. She showed me the itemized bill.
YOUNG: And then here's some kind of a surgical blade or something for over $5,000.
FORTIER: Young contacted the hospital. She even called the manufacturer who made the screws, but she couldn't get straight answers as to why they cost so much, so she sent her bill in to us. For NPR News, I'm Jackie Fortier in Oklahoma.
GREENE: Fifteen thousand dollars for four screws - how does this happen?
ROSENTHAL: First of all, the basic answer is, there's no market for these little pieces of medical equipment - no real market. So...
GREENE: You can charge anything you want if...
ROSENTHAL: You can - I mean, there's no price at all, effectively. So basically, the manufacturer takes a screw that might not be that different than what you buy at Home Depot, they can mark it up to whatever they want, and then the hospital can mark it up however much they want. So what we discovered is that the manufacturers said they normally charged $300 to a thousand dollars for a screw. They wouldn't give us the exact estimate. So that means the hospital, in charging about $4,000 for a screw, is marking it up maybe a thousand percent.
GREENE: Even more, yeah.
ROSENTHAL: Even more. However, what we also did - we took the next step. We went back and said to someone who manufactures generic orthopedic parts, what would it cost to make this? His estimate was about $30.
GREENE: What about these tools that she was paying for, like $4,000 for a drill, $600 for a saw. Can't those be reused? Does every patient have to pay for a new piece of equipment?
ROSENTHAL: Well, what's happened is, over time, we've moved towards more and more disposables, which makes sense with infection risks. But the problem is, there's no market for that, either. You can charge whatever you want for a saw blade or a drill bit.
GREENE: Did she get this resolved somehow or she - she didn't have to pay this, did she?
ROSENTHAL: Well, no, she didn't in the end, but it's not because she herself really got a resolution. I mean, I think the wonderful thing she did, which is so smart, is when she saw this massive charge - a hundred and thirteen or $15,000 - she said, I want to see an itemization. And that's when she noticed the screws were that much. So basically, she didn't get any answers herself. We went on our investigation, and when a reporter called the hospital and the insurer and said, what gives? - they said, oh, it's just a mistake; she doesn't have to pay any of that.
GREENE: So is that the lesson here - we can't trust the hospital; we can't trust our insurance; we have to double-check everything and make sure we're not having to pay mass amounts of money we shouldn't be paying?
ROSENTHAL: Sadly, at this moment in time, I think yes, you always have to have your antenna up. You have to do what you would do in any other part of your life, which is ask for itemization. If there's something you see that looks outrageous to you, complain about it. Complain to your employer, your insurer, to the hospital. Oftentimes, these prices are set assuming that no one will ever see them.
GREENE: Elisabeth Rosenthal from Kaiser Health News, thanks a lot.
ROSENTHAL: Thank you.
(SOUNDBITE OF TEEN DAZE'S "SPIRIT")
GREENE: Now, here's another thing you can do - share your bills with us. Whether they're sky-high or just sort of interesting, NPR and Kaiser Health News would like to see them. You can go to NPR's Shots blog to upload your bill. Transcript provided by NPR, Copyright NPR.