What's a fair price for a stitch?

It's a question that Michelle Boxer would like to answer, since the Ohio woman's two sons are becoming frequent visitors to emergency rooms.

Boxer's 5-year-old needed six stitches to the head in April after he vaulted a couch and landed on a coffee table. The total charges from a doctor and hospital in Dayton came to less than $100 per stitch.

Boxer's other son cut his hand on a broken cup during a visit to suburban Pittsburgh in July. Charges for hospital and physician care at UPMC Passavant Cranberry came to more than $400 per stitch.

"I just want them to explain it," said Boxer, who is contesting the UPMC bill. "I have a hard time paying something when it seems they're just trying to rip me off."

UPMC officials said patient privacy regulations prevent them from discussing the matter, so it's difficult to evaluate the merits of Boxer's complaint. But experts said a variety of factors make it tough for consumers such as her to scrutinize their emergency room bills.

First, all stitches are not created equal. A consumer would need to understand the intricacies of hospital coding to make an apples-to-apples comparison of stitching costs at different hospitals. Second, not all hospitals and insurers are accustomed to share information about their charges and reimbursements.

This could become a larger problem as more consumers are steered into Health Savings Accounts, where they will want to comparison shop since the money will be coming from their pockets more clearly.

"The bottom line is that pricing for medical care, including emergency care, is a confusing mess," said Dr. Arthur Kellerman, chairman of the emergency medicine department at Emory University in Atlanta. "Come to think of it, the whole system is a mess."

Take per-stitch pricing. There are numerous factors that affect the cost, and therefore the charge, associated with repairing a wound, said David McKenzie, a billing specialist with the American College of Emergency Physicians. One factor is location.

Putting a stitch on they eyelid involves considerably more technical expertise than a stitch on the thigh. That's because the facial wound involves more delicate tissue and requires a greater effort to avoid scarring.

Depth of the wound is important, too. Closing a single layer of tissue is easier than multiple layers. Deeper cuts must be cleaned before they're stitched together, and the deeper wound could damage nerves and blood vessels.

Some stitching requires anesthesia, particularly when children are involved. Other stitches require follow-up care, which can affect the overall bill. Depending on the wound, a cut on the hand could require more care because of the risk of tendon damage.

"There are almost 50 codes that could be used to describe putting in stitches, depending on the location and severity of the wound and the resources utilized," McKenzie said. "It's almost impossible to say what the cost involved with putting in a single stitch should be."

It gets worse.

Emergency rooms are always open and are required to care for all patients regardless of their ability to pay, McKenzie said. So, bills for particular procedures are inflated by overhead costs that vary among hospitals.

Overhead costs also can vary based on the level of staffing required in the emergency room. It's expensive to run a trauma center that can handle the most serious patients, for example, and some of those costs get shifted to non-urgent patients.

Finally, few patients end up paying the hospital's full charge for a service. Instead, health plans usually negotiate large discounts off charges, and those discounts vary among plans. So, hospital charges often have a fictional quality, except for the patient with poor or no insurance coverage.

Understanding the logic behind a health plan's discounted price for a particular service can be difficult. Rates are usually negotiated in terms of overall payments to a hospital, not line-item by line-item.

It all adds up to a confusing picture -- and not just for stitches.

Consider the Pennsylvania Health Care Cost Containment Council report released last week on the average hospital charge for a coronary artery bypass graft surgery during 2003. While the statewide average at all hospitals was $92,242, the average charge for the same procedure at Hahnemann University in Philadelphia was $265,193, nearly three times the average. Meanwhile, Jefferson Regional in suburban Pittsburgh reported an average charge of $38,895, less than half the average.

The Pennsylvania council doesn't collect information about stitches, but the Minnesota Council of Health Plans includes some information about stitching costs in a forthcoming publication called "The Cost of Better Medicine." The new study found that knife cuts treated in emergency rooms during 2003 that damaged a hand tendon, required complicated stitches and possibly a tetanus shot generated an average charge of $3,066.

There was tremendous variation in the cost at Minnesota hospitals. One charged $600.25 to care for such a patient, while another hospital charged more than $7,000. In the latter case, the patient spent a night in the hospital.

"It would take an assertive consumer to say, 'In order for me to really understand this bill, I need to ask the hospital for more information,' " said Angie Carlson, a billing expert who conducted the study for the Minnesota Council of Health Plans. "That typically doesn't happen because consumers don't have to pay the whole bill."

Michelle Boxer is paying attention to her bills from UPMC Passavant Cranberry because the hospital was outside her health plan's network, meaning she is responsible for more than one-third of the charges. So she is scrutinizing her bills the way proponents of Health Savings Accounts might recommend.

Called HSAs for short, the accounts typically couple high deductible insurance policies that cover the cost of large health care bills with tax-free savings accounts from which individuals buy other medical services. They have been promoted by the Bush Administration as a solution to runaway health costs.

But Boxer's story suggests the health system isn't ready for these changes.

The Post-Gazette contacted five hospitals to get comparison prices on the six services for which Boxer was billed by UPMC. Mercy Hospital, St. Clair Hospital and Ohio Valley General Hospital could not provide price quotes within 24 hours.

Allegheny General Hospital Suburban Campus in Bellevue provided information for three of the six services provided by UPMC. Tom Chakurda, spokesman for Allegheny General, said he could not provide prices on the other three services because they were not identified by a commonly used coding system.

Only Butler Memorial Hospital provided full information, and the comparison suggests Boxer would have gotten a much better deal at least on the hospital charges at Butler. UPMC's charges were slightly higher than those of Allegheny General Hospital Suburban Campus, as well.

But it's not clear what level of partial insurance coverage Boxer would have had at Butler or Suburban, nor was it possible to make a comparison on physician charges at any of the hospitals.

While it's difficult to make a price comparison after the fact, it might be even harder in advance.

Emergency room workers won't talk about prices prior to caring for a patient because of federal requirements that they treat all comers, said Dr. Jonathan Landis, director of emergency medicine at Allegheny General Hospital's Suburban Campus. Talking finances in advance could be construed as trying to scare away a patient, plus it's impossible to assess a patient's needs over the phone, he said.

Some patients call the emergency room in advance asking about prices, but Beverly Mueller, the nursing supervisor for the emergency department, tells patients she doesn't have information about charges. Mueller says she tells patients that they will receive care regardless of their ability to pay.

People with HSAs, of course, are supposed to worry about the price. A patient with an HSA offered by Highmark Blue Cross Blue Shield gets the benefit of Highmark's discounted rate, so that patient might want to know how Highmark reimburses different facilities before making a choice.

But Highmark doesn't give HSA members information about negotiated discounts, said Kim Bellard, a Highmark vice president. The insurer is reluctant because hospital discounts were negotiated at a time when hospitals believed the information wouldn't be shared publicly, Bellard said.

There's also a practical consideration.

"We could have put out the whole fee schedule to consumers, but is that really of value?" he asked. "The data are overwhelming."

But Bellard agreed that, eventually, health plans, hospitals and doctors will have to provide pricing information that makes sense to consumers.

Greg Scanlan, director of the Galen Institute's Center for Consumer Driven Health Care in Washington, D.C., says the day of simplicity has already arrived in some places. There is a physician in Tennessee who does, in fact, charge by the stitch, Scanlan said.

Hospitals have been less enthusiastic about change, Scanlan said, but they might be forced to by class action lawsuits that have highlighted the high charges uninsured patients receive.

"I think we're entering a whole new world," he said.