Why We Need Transparency in Health Care Costs

Ten years ago, my daughter asked me "Why do we have health insurance if we aren't allowed to see the doctor?" I had a three-day rule where my premise -- most non-serious conditions resolve in 72 hours -- so no need to waste my time or money going to urgent care. Besides, rising premiums pushed me into high-deductible health insurance.

More than a year ago I rushed my younger child to urgent care and the bill remains unresolved. After a heavy object was inadvertently dropped on his finger, causing it to swell 2X its original size, we headed to urgent care the next day when swelling, pain, and movement ballooned.

The visit was brief. Though the front desk clerks were inefficient, the nurse whisked him quickly to the exam room. The doctor's exam was thorough -- he was judged unlikely to have broken bones or require surgery, yet a plain x-ray was ordered to confirm.

So I summarize: time spent included a 10-minute doctor visit, 10-minute x-ray, and 1 hour check-in. The bill arrived a few months later: doctor visit was $426.07 and plain x-ray was $501.38 for the facility and $78 for the radiologist. The $1000+ bill was crazy expensive. My outpatient kidney CT scan a few years ago was under $500, and despite my rule, my son saw the same urgent care doctor the month prior with a lower visit cost ($240.86) and a longer visit time (30 minutes). A friend seen at the same urgent care with a swollen ankle was also billed the lower cost visit.

I assumed they made a mistake. I called Stanford Healthcare to dispute my bill and was told only procedure codes can be disputed. So the rep gave me the procedure codes responsible for each item on my bill. The procedure code matched finger x-ray and the visit code was billed moderate versus low complexity.

Perhaps the x-ray procedure code was billed incorrectly. To find out, I called Aetna, my medical insurance provider, to obtain an estimate for the x-ray procedure code billed. Aetna's rep called back a week later with my estimate: the finger x-ray code billed by Stanford Healthcare in Palo Alto with no deductible paid would cost $124.12. Much more reasonable, I thought. She had a caveat -- the number was an estimate and my bill may be higher or lower. Knowing the actual cost, I asked if my bill might be double or quadruple the estimate and was given a definitive "no."

I was willing to pay $124.12 for a plain x-ray. This began my long appeal process. Stanford Healthcare's only options were to pay my bill or dispute the procedure code. Their patient relations, financial counseling, and guest services were similarly unhelpful. Aetna's appeal process, albeit slow, responded that the code was processed correctly and they "cannot guarantee the accuracy of any cost or estimate. This information is solely for use by our members to allow them to estimate their costs for services by a doctor or facility." Finally, the Stanford University Board of Trustees served as an independent reviewer and assigned me a Stanford Benefits rep who verified my story by locating my recorded conversation with Aetna where I'm given the x-ray estimate of $142.12. Though he expected Aetna to honor the quote, he cites his supervisor's words: "Cost estimates are designed to give members an idea what the charges will be but are truly just an estimate." Cost transparency is not the goal of estimated costs.

Federal protections against surprise bills from out-of-network providers exist but not against surprise bills that don't match insurers' cost estimates. Only the Aetna reps willing to talk to me had any conviction that an estimate should bear any relationship to actual cost. If I choose to self-pay or don't have health insurance, I am eligible to get a good faith estimate where I can dispute a bill more than $400 higher than my estimate. If I have medical insurance and see an in-network provider, my estimate is not required to be accurate.

In fact, the Stanford University administrator in charge of appeals responded to my query regarding price discrepancy by writing, "Stanford Health Care generally is the most expensive provider in the Bay Area relative to other available provider options (and it can be anywhere from 3-10x more in what they charge for services). As Aetna informed you they provide estimates for the costs but until the actual claim is submitted for payment that includes all services and the specific service type code used it is just an estimate."

In 2023 the Consumer Financial Protection Bureau (CFPB) removed medical bills under $500 from impacting credit scores. Some states, including California, passed legislation in 2025 disallowing medical debt from being reported to credit bureaus. The premise is that medical debt is uniquely less reliable for measuring creditworthiness as medical debt is often erroneous or disputed. My experience with medical billing's internal and external appeal process, where the hen oversees its own henhouse, fails. Rather than encouraging patients to ignore debt, which doesn't fix the underlying problem, introduces the free rider problem that will hurt small businesses and not large organizations like Stanford who are further buffeted by a 3-10-fold multiplier.

Do I regret taking my son to urgent care? This experience gave me a window to observe each body, from Aetna, Stanford Healthcare, Stanford Hospital, and Stanford University, pursue legal exoneration to justify to themselves the morally untenable position that a worthless estimate is permissible and somehow helpful. Stanford's new online price estimator gives cost estimates if all insurance information is provided, thereby not allowing cost comparisons, but also with an accuracy caveat.

For a non-profit hospital tasked to benefit the community… I cannot unsee the relentless pursuit of money where Stanford Hospital demands its 3 to 10-fold multiplier even after their insurer may have quoted the usual local rate. That payment is good enough for other providers, but not sufficient for Stanford. Though I had paid the estimated cost prior to appeal, and had a seven-month hiatus of bills after the final appeal, collections sent me a bill for the balance last month.

The protections offered by the CFPB and estimate's accuracy limitations illustrate how the regulations designed to prevent "surprise bills" or price transparency ultimately fail when divine moral law based on love, rather than fear, isn't followed. The laws protect those with financial self-interest to upcode (physician) or collect higher reimbursement (organization re: private insurance). The internal law subject to human conscience and moral intuition would create a more fair system that would enable patients to observe the hospital's irrational pricing variation they'd prefer to keep hidden.

If I were told the correct cost of the visit upfront, what would I have done differently? Perhaps I should return to my first principle, that a swollen finger or twisted ankle isn't sufficiently serious to warrant medical attention. But in the end, we don't know the billed amount until the bill arrives since the visit's complexity level remains a variable. Personally, I'd rather take my car to the mechanic where I'm given a binding estimate prior to agreeing to service.

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