As the health care debate rages on, and everyone waits to see what the future holds for medical services in the United States, there is one big area that is being entirely ignored.

Why does medical care cost so much in the U.S.?

One of my patients recently came to me with her ambulance bill, and wanted to know why she had to pay almost $1,500 for a 4-mile ride to the hospital. Her loved ones had called 911 because she wasn’t waking up, and had trouble breathing.

How could a ride in an ambulance cost more than $300 per mile? Similarly, how could an overnight stay in the intensive care unit cost $10,000 a day?

Medical costs are complex, and there really isn’t a clear way to know how much things cost, especially not before the services are received.

If patients were paying the bills directly, and insurance didn’t exist, would we still be dealing with the same lack of transparency in health care? Or would public pressure result in a greater accountability for the runaway costs, and increase competition among facilities to stay in business?

There are several mystery areas in medicine that illustrate the nebulous accounting that takes place with the cost of care. These include office visits, lab testing, scans and medication.

Office visits are generally straightforward in cost, with or without insurance. There is a set charge, and if someone comes in and wants to pay cash, they are given a 40 percent discount for paying at the time of service.

If people had to pay for their own medicine, would they choose the more expensive one? 

But if someone doesn’t pay at that time, they are sent a bill for the visit. Often it’s three times what many insurance companies have contracted to pay, for the very same service. What I do as a doctor is the same, but the costs could vary by several hundred dollars – why?

When I order lab testing, I have no idea how much those tests cost, and even if I do call the lab to find out, there is a different price for different insurance plans for the very same test. Major insurance companies can often negotiate to pay a lower cost for tests than the general public. Co-pays may run $10 to $30, and the rest is paid by insurance.

What would happen if patients had to pay for labs directly?

For one thing, no one would pay twice for a duplicated lab test. If the lab charged too much for the testing, or didn’t post its rates clearly for all to see, it wouldn’t get any business. Ultimately, transparency would improve. Rather than going to the lab to do the same tests for different doctors on different days, people might be more invested in making sure that they only have to go once, improving convenience and lowering cost. 

Scans are another area of complex billing, depending on where they are done. The same MRI done at a free-standing center costs half of what it would in the hospital. That’s just the bill sent for the use of the machine. Doctors who read the results, known as radiologists, are paid the same no matter where the test is done.

If patients had to pay for their own MRIs, they might consider which place offered the best deal, and there would be competition for business. Right now, it’s just assumed that the test has to be done where the doctor schedules it. But if I’m not looking at the cost, who is?

Medications are yet another mystery. How can a medically recommended hepatitis C treatment cost $80,000? Brand name medicines that have alternatives cost up to five times as much as generic pills.

If people had to pay for their own medicine, would they choose the more expensive one? Could pharmaceutical companies get away with the price-gouging we have seen with the EpiPen, or other medicines, if everyone had to pay directly for their pills? Would people even take so many?

Our current model of health care, even with any potential changes in the works, doesn’t really hold anyone accountable to explain or curtail the cost of services, tests or pills. Insurance helps to mask this lack of transparency, because many people pay premiums, and don’t have to pay the egregious bills for their care.

Having coverage alleviates the responsibility to monitor the overall costs and make sure they’re appropriate. That’s left to the business people who run the hospitals and clinics, and with a 4-mile ambulance ride costing $1,500, it’s clear that price controls are not in place.

In order for any health care program to be effective in reducing costs, it’s going to require a complete overhaul of the system, and a better understanding of what impacts the decisions patients and their doctors make about how to provide the most effective care while taking into consideration the price as well.

That’s going to be a new concept for many of us, but in the long run, it could be the only way to actually lower care costs and keep the entire system running. Whether or not Obamacare survives, or a GOP health care bill passes, the way things are going right now isn’t sustainable.