• Each hospital has a Patients Rights Advocate you can go to for complaints and help. People who use them wish they had gone sooner.
• ​Medicare has a complaint process, and supports advisors at each State Health Insurance Assistance Program (SHIP) for free personalized help.
• ​Patients and family can research treatment options with the resources at drugs.globe1234.com
• Advice on caregiving from nonprofits: Family Caregiver Alliance and National Alliance for Caregiving.
• Caregiver voices: National Domestic Workers Alliance,  United Domestic Workers in California, Coop Home Care Assoc in NY

Patients can get an outside professional advocate, often a senior nurse, to advise them about recommended and alternate treatments. Some will come to the hospital to listen to doctors and advise. Others can interact with patients and doctors on Skype or Google video chat. Cost can be $90-$200 per hour, cheaper than poor health care. As long as doctors and hospitals have hidden incentives to avoid care, patients need expert advocates. (The parallel is with courts, where most people would get a lawyer, in spite of the cost.)

National directories are at:

• aginglifecare.org
  
• advoconnection.com
• nahac.memberlodge.com
• pacboard.org (smaller membership)
• patientadvocates.com (smaller membership)

1. Advice from Kiplinger and Huffington Post and Checkbook
2. aphadvocates.org/ sponsors the advoconnection national directory
3. healthadvocateprograms.com/ lists training programs for patient advocates
4. billadvocates.com links specifically to help on medical bills
5. healthcarebluebook.com lists prices for many procedures
6. Consumers Union has a "Safe Patient Project" to reduce medical errors, with many stories from patients

Free telephone help will not be as effective, but it is free for the very ill from Patient Advocate Foundation on skin, breast, cervix, ovaries, prostate, and colorectal cancer, narcolepsy, heart valves, Aetna claim problems, and dealing with other insurers.

The heavy penalties which Medicare puts on hospitals for readmitting patients, mean that doctors and hospitals may advise patients not to get treatment, if there is much chance of readmission, even when the treatment would help the patient.

So patients need to worry that advice from doctors, hospitals, or Accountable Care Organizations (ACOs) can be biased away from treatment.

Patients who want treatment can avoid being a subject of hospital penalties and hospital risk by:

1. Prevention, which includes diet (such as low salt and fat), exercise, immunizations, medicines, preventing falls. Doctor visits need to address blood pressure, cholesterol, swelling, apnea, and infections before they cause hospitalization. You can check your prescriptions for interactions at MediGuard.org
   
2. Getting a second opinion from doctors not affiliated with the hospital and not in an Accountable Care Organization
3. Arranging assisted living or caregivers and equipment at home so one can go home right after an outpatient operation and stay there successfully. Used hospital beds, bedside commodes, wheelchairs, walkers, alternating pressure pads, and caregivers are affordable. Lift chairs are expensive, but one that goes flat (A or B) will help you up and down from a sleeping position without you having to twist in and out of bed.
4. Long term design changes can be considered whenever remodeling, and there are financing options.
   
5. Avoiding admission to short term hospitals  by using prevention, urgent care centers, long term hospitals, outpatient surgery at a hospital or surgi-centers (though these can have worse outcomes, more risks, and more deaths) and other outpatient services. Patients can use Medicare's software to see if they have high readmission risk, to know if hospitals will be wary of them. Research is looking at more kinds of hospital services which can be given at home.
6. Dropping Part B of Medicare, if you have other insurance. "Medicare Part B is of limited value to someone already covered by a good health plan" (Center for the Study of Services, 2013). Most Medicare penalties and rankings are based on patients who have Part B, so if you drop it, your doctors know you will not affect their penalties. Medicare resists dropping Part B, and if you re-enroll later, they increase the Part B premium 10% for each year you lacked Part B, so it is a significant decision. The form to drop it is CMS-1763 (or copy); in the form part B is called "medical insurance," and part A is called "hospital insurance." Your right is established by 42CFR407.27. 14,000 people per year file this form to drop coverage (p.4 of Statement).
7. If you pay premiums for Part A Hospital Insurance you can drop it too, 42CFR406.28, but Part A is generally free. If you get Part A free, then the only way to drop it is the draconian step of refusing Social Security payments and repaying any Social Security and Part A benefits you have received. This rule was approved by the federal Circuit Court in DC in 2012 (Hall v. Sebelius); page 4 of the dissent (p.11 of the pdf file) analyzes this Social Security policy. The Supreme Court decided not to hear an appeal. Dropping part A involves the same form listed above for part B.
8. Federal retirees can opt out of Part A with fewer problems than most people. Many federal retirees lack Social Security and have federal health insurance. Even if they drop Medicare, they get charged the same as Medicare patients for hospital inpatient treatment, and for doctors who participate in Medicare (and up to 15% more by non-participating doctors). Outpatient hospital care and non-physician based care (e.g. PT, nursing homes) are not covered by this requirement for equal charges; regular Plan benefits apply. These costs are in each plan brochure, in a section titled, "When you are age 65 or over and you do not have Medicare." The limits were established by laws in the 1990s: Omnibus Budget Reconciliation Act of 1990~P.L.101-508 §7002, p.28; and of 1993~P.L.103-66 §11003, p.30.
9. Using a VA or military hospital if eligible. Members of Congress can use Walter Reed military hospital.
10. Using a specialist hospital (usually with better than average care). The following are exempt from readmission penalties: "rehabilitation hospitals and units; LTCHs [long term care hospitals]; psychiatric hospitals and units; children's hospitals; and cancer hospitals. Religious nonmedical health care institutions (RNHCIs)" 
11. Using a hospital in Puerto Rico (exempt) or Maryland (exempt, even famous hospitals like Johns Hopkins). Medicare's head office is in Maryland, so retirees and family members there do not face Medicare's readmission penalties.
12. Using a top hospital abroad; these are not covered by Medicare.
13. Using a Critical Access Hospital (small, rural, isolated, exempt, marked in "Combined list") if it has the skills you need 
14. In a US hospital, Medicare patients generally cannot pay privately: 42 U.S.C. § 1395cc(a)(1)(A)(i) says a hospital cannot charge or accept private payment "for items or services for which [an] individual is entitled to have payment made under [Medicare, Part A]" (p.16, note 9)
15. If staying overnight at a short term hospital, consider getting it called observation, rather than being admitted. Drugs will cost more, and it will not entitle you to covered nursing home care, but the stay will also not count toward a readmission penalty.
    
16. Joining a Medicare Advantage plan (may promote hospice aggressively, and limited appeal rights). They are paid a flat rate per member, so they need to minimize all hospital stays and other expensive care, but they have no specific incentive to avoid readmissions.
17. If there is any ambiguity in your principal diagnosis, you can try to convince the hospital to avoid having it be one of those that have penalties (Table A).
18. Lobbying Congress to repeal or reduce the penalty

Regardless of exemptions, it is possible doctors who primarily see ordinary Medicare patients will have a habit of minimal treatment, even for managed care and private insurance patients exempt from the penalties.

Insurance premiums for Medicare and Medigap policies are described in 9 pages on SeekingAlpha. There is also information on SeniorCare and Medicare Rights Center about differences in Medigap plans. Medigap covers a lot of copays not covered by Medicare Part A and B. You can't use Medigap if you have Medicare Part C (Medicare Advantage). If you don't get a Medigap policy when you start on Medicare, in most states you may not get it later.

• Only four states (CT, MA, ME, NY) require Medigap plans to offer continuous or annual eligibility for people with pre-existing conditions.
• In all other states and D.C., people who switch from a Part C Medicare Advantage plan to traditional Medicare may be denied a Medigap policy due to a pre-existing condition, with few exceptions, such as if they move to a new area or are in a Medicare Advantage trial period. This denial may lock you into Medicare Advantage, with its limited networks, limited appeal rights, and sometimes worse care for the sickest patients (12% higher death rates and more preventable emergency room visits for non-elderly in California 2009-2013).

Several groups have proposed changes in Medicare premiums. Cancer Today discusses high drug copays.

Community Health Centers get federal grants and often have lower costs than average.

Cost disclosures are in flux. Checkbook has a good article.

The Wall Street Journal has a good free guide to looking for health care costs, no matter if you pay with Medicare, other insurance, or cash. Finding costs before you get treatment is hard. Dr. David Belk explains about the confusing cost of office visits, including higher pay from HMOs than from fee-for-service. The Atlantic describes 2019 laws and practices of debt collection for unpaid hospital bills.

Each patient's cost depends on his or her insurance.

• Insurance companies negotiate costs, and patients pay this up to their deductible or copay.
• For understanding and negotiating Medicare coverage and some aspects of medigap policies, help is free.
• A 2020 HCCI survey lists (a) average cost paid by private insurance, (b) average cost that would have been paid by Medicare, (c) numbers of patients and providers. These are in 2 spreadsheets: (1) summary for each state and metro area, (2) detail for each type of office visit or injection for each state and major metro area. Summary citing previous studies and methods.
• A 2019 RAND survey lists 1,600 hospitals and the average prices negotiated by insurers for inpatient and outpatient care, as multiples of Medicare prices (averaging 2-10 times as high for outpatient care, 2-4 times as high for inpatients): xlsx list of 1,600 hospitals, pdf summary, AHA comment.
• For people without insurance, the Medicare level for each service, and the private insurers' averages, are starting points for negotiation.
• In order to know total costs, patients can ask the doctor's office whether an anesthesiologist, assistant surgeon or hospital fee will be needed.
• Anesthesiologist fees are in the Specialists tab above.

Doctors' fees under Medicare are in the Specialists tab above. They show what Medicare pays, and the list price for each procedure from each provider. Medicare costs include the total paid by Medicare, supplemental insurance and patients.

Hospital fees for the most common 100 diagnoses are in hospital spreadsheets from Medicare, and are mapped nicely at ClearHealthCosts. 

For example the data files show that surgeon costs for knee replacement are typically around $1,500, assistant surgeon $300, anesthesiologist $200, and hospital costs (for "major joint replacement or reattachment of lower extremity") averaged $14,000 if there were no major comorbidities and complications (MCC), or $23,000 if there were.

For a few procedures (primarily imaging, tests, counseling, dental extractions or implants, cosmetic procedures), ZendyHealth gives (free) a range of local prices within a radius you choose. They offer you a doctor based on how much you want to pay ($49 referral fee). You cannot use insurance with the doctor, but Zendy helps you submit a claim to your insurance company, so your cost counts against the deductible. For these and other procedures they offer a free consultation. You have to pay their legal bills if there's a problem ("indemnify"), and accept arbitration. You have no choice of provider, and see the name assigned to you only after you have paid the referral fee. For example different MRI centers have different strength magnets, and you are likely to get the cheapest, weakest magnets, which give less precise images. If you have time to search the Specialists tab above, you can find the lowest price providers and negotiate directly.

Costs in New York state are at pndslookup.health.ny.gov/

Costs for treatments in North Carolina are available from Blue Cross/Blue Shield of North Carolina, based on their patients and their contracts with providers: bcbsnc.com/content/providersearch/treatments. These have actual costs for a treatment episode, including hospital and doctors. Very easy to access. The free system compares all providers within any radius of a zip code, up to the whole state. You can sort by cost, name or distance. However there are only 1,200 procedures, no info on how often each doctor does the procedure, voluminous output with typically 3 providers per screen, not downloadable, only North Carolina, no procedure codes, so it is hard to be sure what each item covers,  no lab costs or drug costs. Their data come from one year, but they don't say which year.

Doctors' incomes derive from the payments above and the volume each doctor does. Average incomes (after expenses)  by specialty range from $240,000 per year for Public Health and Pediatrics to $580,000 for Plastic Surgery, with wide variation. Top pay is in KY, TN, AL, MO, probably because of standard payments combined with lower costs. Concierge practices have 1% of doctors. The most rewarding parts of the job are gratitude and relationships with patients, doing a very good job and making the world better. They average 15 hours per week on paperwork and administration.  27% would not choose medicine again, varying by specialties. Wealth averages $1-2 million, depending on specialty and age. A quarter of doctors have over $1 million by the time they are 35, and two thirds do by the time they are 50.

​Most doctors at hospitals work for large groups (TeamHealth, Schumacher) which contract to provide hospitalists, radiologists, emergency doctors, etc. Some companies provide doctors to hundreds of hospitals (Envision + Amsurg). Hospital doctors earn $200,000 - $400,000 per year. About half feel fairly compensated. Only a quarter "regularly" discuss the cost of treatment with patients. Over three quarters would choose medicine again and the same specialty.

Insurance payments are complex, and are further discussed throughout this site. A glossary defines insurance terms.