At Peninsula hospitals, patient payments only loosely tied to charges

According to spokeswoman Cheri Hinshelwood, Sentara Healthcare uses the cost of providing care, rather than the much higher charges, for the charitable write-offs. In 2012, it provided more than $250 million, "for a very conservative estimate," she said.

Who pays?

The patients most affected by the differences in billing charges are therefore those, like Pouchot, with a high-deductible policy, the underinsured — because discounts are typically not applied to co-payments or deductibles — and the uninsured.

Unlike other goods and services, health care typically costs the self-pay consumer what the provider believes they can afford to pay. "Discounts are based on income," said Broermann. Sentara has a policy of writing off 70 percent of the gross charges for the uninsured who fall between 201 and 600 percent of the FPL. For families with incomes over 600 percent of the FPL, the discount is 30 percent.

New regulations under The Affordable Care Act have driven changes in billing for the uninsured or self-pay patients. Discounts must now be based on an average of the hospital's three lowest negotiated commercial insurance rates.

Riverside starts with the highest charge and then applies discounts according to income and family size. It has instituted patient financial navigators who are authorized to apply further discounts to help work out payments. "They determine what is affordable for that patient. Historically we took a very math-based approach. We're returning to a more personal one," said Woughter. Payment plans are geared to a five-year maximum, and the system runs occasional specials; this month (June 2013) it's offering a 20 percent discount to anyone who pays off an outstanding balance.

Bon Secours uses data from the Tax Foundation to limit a family's out-of-pocket expense to an appropriate percentage of income, less than 15 percent, to determine a maximum annual obligation. "Charges are identical regardless of the payer source," Ingold said. Discounts for self-pay patients typically bring a bill down to generally what a patient with insurance is paying, he added.

Will it change?

There are many barriers to free competition and transparent billing in health care, from the COPN system in Virginia, the structure of insurance, the need for charitable care, and the nature of health care itself. "If you have a bone sticking out of your leg, do you call around for the cheapest place?" asked Pouchot to illustrate the point.

Still, more questions are being asked and the conversation has begun in earnest.

Want to compare charges?

Several sites have information on different hospital charges and average costs. The information, however, doesn't translate into what individual patients pay.

The Centers for Medicare & Medicaid Services, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html; search by region and hospital for average costs of different procedures at http://www.vapricepoint.org/ ; for quality of care and other measures, go to http://www.vhi.org.