Experiments designed to charge a predetermined fee for common surgical procedures offer a glimpse into the future of healthcare spending.

Wildly different prices for the same medical procedures often leave consumers bewildered and financially ruined. Charges are all over the map. Here in Southern California, the hospital cost alone for hip-replacement surgery typically runs from about $103,000 at UC Irvine Medical Center to $41,000 at Hemet Valley Medical Center. The variation is influenced by myriad factors. Facilities that offer expensive specialty services such as trauma centers, burn units or transplant programs tend to charge more for care. Meanwhile, hospitals often charge privately insured patients more to make up for what they lose on uninsured patients and relatively low reimbursement rates from Medicare. Caregivers and hospitals point out that they receive only a fraction of charges they submit, whether to insurance companies or the federal government. Like the patients they serve, they, too, welcome more predictability. Many providers and insurers say they are now ready to experiment with new ways to cut unpredictable healthcare spending.

In one closely watched test beginning in August, several of California's best-known healthcare providers -- including Cedars-Sinai Medical Center, the UCLA Health System, and Hoag Memorial Hospital Presbyterian in Newport Beach -- will begin charging lump-sum fees for hip and knee replacements. Doctor bills, X-rays, artificial joints, tests and hospital care are among the fees that will be wrapped together for commercially insured patients who would otherwise be charged for each service. The single charge will vary from hospital to hospital based on the fee each negotiates.

The lumped charges for hospitals and doctors will cover most aspects of medical treatment from surgery through 90 days of recovery. That's a radical departure from the traditional practice of hospitals and doctors charging separately for their services, a fragmented system that drives up costs while leaving no one to coordinate decisions about patient care. Hospitals and doctors say they expect to share in savings when patients recover promptly, while bearing the risk of additional expenses when complications arise.

The federal government already is testing similar "bundled" payments for its Medicare program in Colorado, Texas, New Mexico and Oklahoma. And President Obama's new healthcare law calls for exploring additional arrangements for surgical services for the elderly and the poor.

CT scans sent by smart phones are clear enough for accurate diagnoses.

Let's say, your daughter is away on a school trip. she's having abdominal pain. The ER doctor at the local hospital suspects appendicitis, but wants a radiologist to look at the CT scan images. There isn't one available at the moment. Using a $19.95 iPhone app, downloaded from iTunes, the images are sent to the radiology department of a teaching hospital more than 300 miles away. Within minutes the appendicitis diagnosis is confirmed and the appendectomy performed without further delay.

Study Proves Accuracy

This scenario mirrors a recent study in which researchers (Asim Choudhri, MD, a fellow in neuroradiology at Johns Hopkins performed the study while at the University of Virginia) took CT images of 25 patients suspected of having appendicitis and sent them via iPhone to five radiology residents. Then, the residents were asked to make a diagnosis based on what they could see on their phones. Only one reader failed to make the right diagnosis. In every other case, the residents correctly determined that 15 of the patients were suffering from appendicitis and that 10 of the patients did not have appendicitis and did not need treatment.

Elliot Fishman MD,, director of diagnostic imaging at Johns Hopkins University, says ,"The promise is that we can look at anything anywhere. The technology can expedite diagnosis and, therefore, treatment."

You'll find the Mayo Clinic near the top of the list of the best of the best in medical care. In the media, the Mayo Clinic is depicted as a place where rich and famous people with serious illness go to be treated. You would be hard pressed to find a better brand name in the health care field.

Cost Effective and Superior

One rarely thinks of the Mayo Clinic as a model of cost-effective medicine. Yet they are known for lower than average costs and better than average quality. Mayo Clinic CEO Denis Cortese was interviewed on NPR recently. When asked if the Mayo Clinic could be used as a model for health care reform that could work everywhere, "Yes", he said, "the Mayo model is transportable, but with difficulty".

Salaried Doctors

"The key ingredient is instilling a culture among physicians that puts the needs of patients first", Cortese said. One of Mayo's secrets is putting doctors on salary. One wonders how Mayo is able to attract the best doctors? "Pay at Mayo is competitive and turnover is low, despite the salary approach", Cortese said.

The Patient Experience

"Paying doctors by the procedure, or for treating sicker people can create conflicts", Cortese opined. "When it comes to the patient's experience, taking a doctor's pocketbook out of the care equation makes a big difference."

Cortese suggested that Medicare payments to providers of health care could be based on the value they provide--not the number of procedures they perform. If Medicare paid providers of good value care a little more--enough to give them a 2% profit margin--practices like Mayo's would grow indefinitely," he said. "If doctors end up doing less, keeping people healthier or keeping them at home, they may actually make no money."

Would it surprise anyone to learn that drug use is widespread among hospital employees? I think not. There is even a new TV show called Nurse Jackie, whose main character played by Edie Falco, is clearly addicted to prescription drugs and trades sex for drugs with the hospital pharmacist. The creators of the show have made the Nurse Jackie character the most competent person in the show's fictional hospital. That's all well and good when it comes to creating an edgy adult TV drama, but not in the real world. Real addicts are only competent in their own minds.

Meet Nurse Melony.

According to a recent Los Angeles Times article exposing the failure of the California Nursing Board Drug Diversion Program to protect us from nurses on drugs, Nurse Melony Currier is a poster child for nurses on drugs. In one episode, Nurse Melony passed out in her car the morning of her second day on a new job at Starpoint Surgery Center in Studio City, California. Once awakened, she was escorted to a drug-testing facility to provide a urine sample. In the restroom, she injected an anesthetic she had stolen from the surgery center, according to state records and a Starpoint official. Currier had failed repeatedly -- and spectacularly -- at rehabilitation. Over 4 1/2 years, she'd been discovered high in her car at a Hollywood hospital, stolen anesthetics at a San Gabriel Valley hospital, been convicted of burglary after taking more drugs from the same hospital and flunked a drug test.

Melony Currier first landed in trouble on Nov. 8, 2001, when she was arrested for stealing Demerol from Providence St. Joseph Medical Center in Burbank, CA. (She later told board investigators that she'd stolen drugs every day for months.) Nearly two weeks after her arrest, while working at Planned Parenthood in Van Nuys, she was found collapsed in the bathroom, injecting herself with the general anesthetic propofol - the stuff that killed Michael Jackson. Two days after that, she returned to Providence St. Joseph and stole more of the drug, board documents say. She was later convicted of misdemeanor theft in the Van Nuys case and petty theft and drug possession in the Burbank case.

Currier, then known by the last name Dietrich, was allowed into the California Nursing drug diversion program in February 2002, The program finally expelled her in 2006 -- after the five relapses. A month after Currier was ejected, according to board documents, she went to Providence St. Joseph, where she'd been arrested five years earlier. Posing as an employee, she said she'd come to collect drugs for outpatient surgery. When questioned, she "fled," board records say, driving 10 miles to Verdugo Hills Hospital in Glendale. Again posing as an employee, she stole two cases of propofol, according to court and board records. Two days later, on Oct. 18, 2006, Currier was arrested when she returned to Verdugo Hills for more.

The California nursing board filed a public accusation against Currier in March 2007-- nearly 5 1/2 years after the agency first learned of her drug problems. When the board settled the case in 2008, Currier's license was suspended for one year and she was put on probation. As part of the settlement, she admitted the allegations. Currier is now free to practice nursing with restrictions.

She may stay off drugs, but it seems unlikely. How many more patients will have to suffer because of Nurse Melony and others like her?

Yes. Your hospital bill is negotiable.

What hospitals accept for payment is not set in stone. There's the hospital's list of charges and then there's what they actually collect. Hospitals are required to offer discounted or free care to patients who meet financial eligibility guidelines. And most will negotiate with any patient having difficulty paying their bill. It's best to have such discussions before care takes place. It can enable the hospital's billing office to help find some assistance, such as Medicaid, Medicare or private and hospital charity assistance if the patient is eligible. Uninsured patients have the right to negotiate even after hospital care has been given, with the best deals often offered to people who agree to share their financial information and show a willingness to start paying the bill. Here are 7 tips to help you save money on your hospital bill.

1. Let your doctor know your financial circumstances

Get a full picture of what will be done during your stay, as well as any related tests and follow-up visits. If you're worried about paying the hospital bill, ask whether it's safe to delay the treatment or procedure. Perhaps you need surgery for a sinus condition that's bothersome but not life-threatening. A delay, if approved by your doctor, is an especially good idea if you or a spouse is in line for a job that will pay health benefits or if you've maxed out your flexible spending account for the year. Also ask if there are tests that can be avoided safely, such as for cholesterol and glucose if you've recently had those checked.

2. Choose a non-hospital if possible

One way of saving money might be to avoid the hospital for some procedures. Consider having tests and procedures, such as colonoscopies, MRIs and CT scans, done in independent surgery or imaging centers, or at an accredited doctor's office. This can save hundreds of dollars. Hospitals have far higher expenses, including a large physical plant, a larger staff and the need to write off millions of dollars in care for people who don't pay or who pay at a reduced cost. Your doctor should be able to recommend independent.

3. Shop hospital costs

Some websites, like Healthgrades , can tell you what many area hospitals charge. Healthgrades charges about $8 for a report. Finding the least expensive hospital can lower your out of pocket costs greatly. For instance, costs for a caesarean section in Southern California vary from $18,000 to $30,000, excluding doctor costs, depending on the hospital selected.

4. Check out financial assistance

Meet with a financial counselor at the hospital as soon as possible. Hospitals are required by law to let patients, insured or not, know about the availability of charity care, discounts and government programs that can cover all or part of their bill and about any other programs that can help take care of hospital charges. You may qualify for free or discounted care if your income is below 350% of the federal poverty or your medical costs are more than 10% of your family's annual income.

5. Be prepared when checking in to the hospital

Expect hospitals to ask for payment for the deductible and any other patient share of the bill before service. You don't always have to pay the deductible or your share of the hospital bill immediately, but you do have to come up with a plan to pay it off. Don't use a credit card to pay a hospital bill, unless you're sure you'll be able to pay it off in full by the due date. Letting the credit card bill go past one cycle adds interest fees and could increase your interest rate. Also, it's virtually impossible, to negotiate charges once they've been paid by credit card. A better idea is to ask the hospital for a no-interest rate payment plan. If you can't foot your share of the bill, hospitals might be able to discount your deductible, copay or coinsurance if you qualify under its financial screening process.

6. Get an itemized statement

Insured patients will typically get a summarized billing statement; the insurer gets more specific cost information. Request an itemized bill and ask the hospital for deciphering help if needed. Hospital bills often have errors in them, including misplaced decimal points, charges for tests or procedures not done, even care on days you weren't in the hospital. Look for charges you think were unnecessary. For example, if you recently had a cholesterol blood test, but the bill shows another one you were not told about beforehand. If your bill is huge, you may want to hire a medical billing advocate.

7. Don't ignore your bill

A bill for cancer surgery or an appendectomy or a meniscus repair has to be paid. Ignoring it will simply result in it being turned over to a collection agency. You cannot negotiate with the hospital to lower your bill once it's been turned over to a collection agency.