A popular anti-insomnia medication, zolpidem (Ambien, sanofi-aventis US), increases the ability to remember images, but only those that have negative or highly arousing content, new research shows.

Investigators at the University of California, Riverside, improved memory by pharmacologically manipulating sleep in 28 healthy volunteers.

Although the participants did not have sleep problems, study coauthor Sara Mednick, PhD, said that the findings have potential ramifications for patients prescribed zolpidem for relief of insomnia due to anxiety disorders, including posttraumatic stress disorder (PTSD).

"Physicians should watch out for this countertherapeutic effect in patients with anxiety disorders and PTSD," Dr. Mednick toldMedscape Medical News. "These are people who already have heightened memory for negative and high-arousal memories."

She cautioned, however, that it is premature to warn patients taking this drug of the potential for increased recollection of sad, frightening, or stimulating memories, saying further research is needed.

The findings were published online June 14 in the Journal of Cognitive Neuroscience.

Manipulating Memory

The study also identified sleep "spindles" as the mechanism that enables the brain to consolidate emotional memory. Sleep spindles are brief bursts of brain activity that occur primarily during non–rapid eye movement (REM) sleep.

Previously, Dr. Mednick and colleagues found that sleep spindles play a critical role in consolidating information from short-term to long-term memory. Other researchers have focused on REM sleep as key to emotional memory, but Dr. Mednick's group found in the current study that sleep spindles, not REM sleep, affect emotional memory.

These findings give hope that memory can be manipulated in positive ways, said William Kohler, MD, a spokesman for the American Academy of Sleep Medicine in Darien, Illinois, and the medical director of Florida Sleep Institute in Spring Hill, Florida.

Dr. Kohler, who was not involved in the study, told Medscape Medical News, "The more we know about the processes in memory, the better our ability to intervene clinically in patients with emotional problems and memory problems such as dementia — patients who have a high prevalence of insomnia."

The study included 15 men and 13 women, aged 18 to 39 years, all of whom were normal sleepers. The researchers used 2 hypnotic medications, zolpidem and sodium oxybate (Xyrem, Jazz Pharmaceuticals, Inc.), to pharmacologically manipulate sleep spindle density, which they defined as the number of spindles in stage 2 divided by the minutes of stage 2.

The authors note that previous research has shown that zolpidem increased spindle activity, whereas sodium oxybate decreased it.

On 3 separate occasions in this crossover design, the participants received, in an order that was "counterbalanced across participants," 10 mg of zolpidem orally, 2.5 g of sodium oxybate, or a placebo, with at least 5 days between study days to allow for drug washout.

On the study days and 2 days before, participants reportedly did not consume alcohol, caffeine, or stimulants.

Participants performed a memory test before and after a 90-minute morning nap in a polysomnography-monitored sleep laboratory, where they had spent the preceding night.

To encode memories before the nap, participants viewed on a computer monitor 100 target images, 20 from each of 5 stimulus groups known to evoke positive, negative, or neutral responses.

The groups were as follows: (1) positive, low arousal, which Dr. Mednick said included an image of a kitten; (2) positive, high arousal, such as a picture of a roller coaster; (3) negative, low arousal, for instance, an image of people gathered around a grave site; (4) negative, high arousal, such as a picture of a snake about to attack; and (5) neutral images, such as a tree.

Participants received the study drug immediately before the nap. Several hours after their nap, they performed a memory retrieval test, which involved viewing the same 100 target images, which were randomly rearranged and mixed with 100 new, irrelevant images.

A computer prompt asked them to respond by indicating how certain they were that the image was old or new, to determine memory accuracy ("memory discriminability").

Ceiling Effect

Electroencephalography tracked sleep spindles in stage 2 sleep, with the electrodes at C3 and C4 positions.

Sleep spindles, Dr. Mednick said, appeared to be vital for enhancing emotional memory. The participants' sleep spindle density was significantly higher when they received zolpidem before sleep and significantly lower with sodium oxybate compared with placebo. Reported results (mean ± standard deviation) were 3.23 ± 1.38 for zolpidem, 1.93 ± 1.24 for sodium oxybate, and 2.67 ± 1.58 for placebo (F[degrees of freedom 2, 54] = 13.18; P < .001, 1-way analysis of variance).

In contrast, memory accuracy was significantly better in zolpidem-enriched sleep (P = .005) vs placebo, but not significantly better with sodium oxybate, the researchers reported.

They found, however, that increasing sleep spindle density was associated with increased memory accuracy for highly arousing and negative stimuli only when the participants received sodium oxybate.

The authors suggested that the lack of a significant positive correlation between spindle density and memory accuracy with zolpidem might be because that drug does not produce a great enough range of spindles, creating a "ceiling effect."

High Specificity

The significant difference in memory accuracy with zolpidem existed for both negative and high-arousal stimuli but not for positive or low-arousal stimuli.

"I was surprised by the specificity of the results, that the emotional memory improvement was specifically for negative and high-arousal memories," Dr. Mednick said in a statement.

Dr. Kohler said he also found the effect that zolpidem had on memory surprising.

"This article, even though a relatively small number of patients were involved, does give some correlation between zolpidem and increased spindle density, which was found to increase memory discrimination. It's very interesting, but whether it's replicable in other studies, we don't know yet. We need to do a lot more investigating."

Because benzodiazepines produce similar effects on sleep as zolpidem, Dr. Mednick said that future research should investigate whether benzodiazepinelike drugs increase retention of negative and arousing memories, especially in patients with PTSD.

The US Department of Veterans Affairs (VA) in 2010 recommended against treatment of PTSD with benzodiazepines, but the VA's National Center for PTSD reported that 30% of veterans with PTSD are still prescribed benzodiazepines in the VA system (PTSD Res Q, 2013;23:1).

This study was funded by an award from the National Institutes of Health.

“Popular Sleep Med Heightens Recall of Negative Memories: Findings May Have Clinical Implications for Patients With PTSD and Other Anxiety Disorders” by Kathleen Louden for Medscape on Jun 25, 2013

A spike in the number of adverse event reports (AERs) associated with the da Vinci® Surgical System (Intuitive Surgical®, Sunnyvale, California) last year has prompted the US Food and Drug Administration (FDA) to survey surgeons about their experience with robot-assisted surgery. The number of AERs increased 34%, going from 211 in 2011 to 282 in 2012. During that period, the number of procedures performed with the da Vinci system in the United States increased 26%, going from 292,000 to 367,000.  Medscape spoke to Joseph Colella, MD, Director of Robotic Surgery, Magee Women's Hospital, University of Pittsburgh Medical Center, and a founding member of the Clinical Robotic Surgery Association, about the FDA survey and the current state of robotic surgery in general.

Medscape: Do you think this FDA survey is warranted? And to what would you attribute the increase in AERs?

Joseph Colella, MD: When a new technology is being used and adopted in a relatively rapid fashion, oversight of that new technology needs to be very carefully employed. Learning-curve issues can arise, just as they did when we adopted laparoscopic technology.

AERs can be due to lack of training, to inappropriate use of this technology, or to the technology itself. In the case of AERs and robotic surgery, in the numbers that you quoted, there's a roughly proportional increase relative to the AERs and to the volume of cases done. It's not quite one to one, but it is relatively close.

One can also take into account the fact that as the technology is becoming more widely adopted, the individual hospitals that are using it have also matured relative to their ability to scrutinize events as they occur, report them, and then collect the data. As the hospital systems' ability to do these things developed, of course you are going to get more AERs. They are looking in places and for events that they were not looking in before. When I talk to other robotic surgeons, we seem to have a fair amount of unanimity that the increase in the numbers of these events is really due to the maturation of the oversight process among hospitals and individual hospital systems.

Medscape: Is this different from when laparoscopy was introduced?

Dr. Colella: The curves of adoption and adverse events that occur with robotics and that occurred with laparoscopic surgery are very similar, and I would go so far as to say they are almost identical. I should add that we're still learning today about complications and adverse events that occurred in laparoscopic surgery years after its widespread adoption.

Medscape: What are some of the most common and avoidable AERs that occur with robotic surgery? And do they tend to be due to surgeon or machine errors?

Dr. Colella: I'll take the answer to your last one first. Any time that you introduce a technology, it has to be employed correctly by appropriately trained people who know how to use it. I was trained in the open era, and in the last few years of my training we began using laparoscopy. I went through the entire laparoscopic evolution from 0 to 100 miles an hour, and now I am living through and helping to lead the robotic evolution and seeing the same events. But, because robots are involved, we now seem to be chasing events that have been occurring all along throughout the course of laparoscopic surgery.

As I mentioned, the adverse events with laparoscopy and robotic surgery are almost identical. For instance, one of the more commonly reported ones with both is inappropriate arcing of a coagulation device, where it injures a piece of intestine and is not witnessed or recognized at the time of the event. Everyone is trying to capture and report this with robotic surgery, and it's appropriate to do so.  However, those same events happened and still happen with laparoscopic surgery, and you don't see the FDA investigating laparoscopic technology independently, as they do now with robotics.

Medscape: Robotic surgery adds the complexity of the machinery, however. Are there many errors that can be attributed to the technology itself?

Dr. Colella: In my experience, I have never had the robot malfunction in any way. The adverse events that I have heard about can almost universally be attributed to surgeon error, to user error, or to some other event that is related to either personnel in the operating room or a distracting event that may involve the robot but is not in fact the fault of the robot. The complexity of the machinery actually makes most operations easier.

Medscape: Of course, these are all relatively new machines. No one knows how they're going to behave over time or at what point they will begin to break down.

Dr. Colella: There is definitely some truth to that. I've had the privilege of using a brand new machine for 1 year at one hospital and then moving to another hospital where they also had a brand new machine. I've had a unique experience in that I haven't had to use the same machine for 5 years, so I can't tell you personally what those 5 years would look like. However, I can tell you that the company has built a very intense support system that we haven't had to use very often. On those rare occasions when there has been a problem with the robot, for example as part of its setup or after an operation when someone notices a fault light, the engineering teams have been very good about responding.

Medscape: One of the major issues in the use of the robotics is the price. The machine itself costs between $1.5 and $2.2 million dollars. In addition, the service contracts run from $160,000 to $170,000 per year. Then disposable instruments range from $600 to $1000, and each procedure can use 3-8 instruments. Given that, do you think these machines will ever become as cost effective as the use of laparoscopy?

Dr. Colella: This is a very general question, and it boils down to using the robot for the appropriate indications. Let's take the example of a hysterectomy: It's a major advance when you can take a patient from an open to a minimally invasive procedure using the robot. It has an impact on that patient's overall life in a very substantial, beneficial way. The cost is ultimately realized in terms of savings—from length of stay in the hospital to lower complication and readmission rates. All of these are much improved with the robot versus an open procedure for a hysterectomy.

Also consider that in bariatric robotic surgery the bleed rate approaches zero, the major complication rate is less than 0.3%, and there have been no reported deaths in robotic bariatric surgery. Then factor in the substantial reduction in stricture rates, which cause postoperative readmissions and procedures, and the use of fewer staples than in laparoscopy. You can begin to realize the cost savings with robotic surgery and that it does not take very many cases to realize those savings.

Medscape: I know that you specialize in bariatric surgery, but are there robotic procedures that you think will eventually be most or least advantageous?

Dr. Colella: Well, as a potential patient, stop for a moment and put on the common sense hat. Your surgeon tells you that he can see 100% better in 3 dimensions, that he can sew better, and probably within 1-2 years he will be able to do every procedure through 1 incision. You can imagine that the sky is the limit in employing robotic surgery. It's an enabling technology. I firmly believe that we are finding new and beneficial applications almost on a monthly basis.

For instance, nobody ever thought that you would be able to resect tumors of the larynx without taking half of the face apart to get to them. With the robot in the right hands, you can do those operations in an hour, and the patient goes home the next day.

Another example that will be a tremendous game changer is when you can do robotic gastric bypass with a single 15-mm incision in a 600-lb patient, who goes home the next day with the same safety profile that I just talked about. Robotics have enormously minimized the trauma that these patients face from the surgery and have lessened the need for pain medication, which allows much quicker gastrointestinal recovery, which, in turn, reduces the incidences of pneumonia and aspirations. This technology is making impacts in ways that aren't even obvious to some of the people who employ it.

Medscape: What about the visual field? I know with laparoscopy that was one of the disadvantages compared with open procedures. Is that an issue with robotics?

Dr. Colella: The robotic visual field is somewhat smaller than the laparoscopic visual field. However, you quickly adapt and know the limits of your vision or the lack of them. The slight reduction in visual field is insignificant for me, and one might argue that a bariatric operation is one of the most complex procedures done either robotically or laparoscopically. I don't perceive visual limitation to be anything of a disadvantage. As a matter of fact, with 3-dimensional vision, with the ability to see better in any spot than I ever could with laparoscopy, it changes the game in a very positive way. I don't see that a slight reduction in the visual field has any impact on my ability to perform a procedure, given the other benefits from using robotic instrumentation.

Medscape: I read some complaints about the way surgeons are being trained in robotic surgery -- that it's rushed and insufficient in many cases. Have you heard anything about that?

Dr. Colella: I've heard this. I can only speak to my experience with the development of robotic surgery at the University of Pittsburgh, which has been similar to the support and training of surgeons across all specialties there who use and employ the robot. The support provided me in learning the robot with bariatric surgery was above and beyond what I was ever expecting. Maybe there are places where they've rushed training, but my colleagues and I have not seen that.

Medscape: Do you see any competitor to da Vinci on the horizon?

Dr. Colella: No, and I'm pretty tuned in to that world because I live in it. Other technologies are attempting to enter that space, but right now the barriers to entry are very significant. It's going to be very difficult for another technology or another company to live up to the track record that has been established. I have nothing to disclose. I have no personal interest in them. I have no financial relationship with them. I just use their products.

Of course, it's inevitable that eventually there will be competition, However, I have not seen a product or a technology that I was interested in trying in any meaningful way that was even remotely comparable to the experience that I have with da Vinci.

Medscape: A major disadvantage, of course, as with any monopoly, is that they can name their price. At this point, the only competition is to return to or just stay with laparoscopy as the alternative to the open procedures.

Dr. Colella: Yes, that's right. However, these hospital systems that are continuing to adopt robotic technology are not doing so just to keep up with the Smiths and the Joneses. If it wasn't making or saving them money, they would not use it. At the end of the day, if this is a money loser, it's not going to be around.

Medscape: So you're seeing this as an almost universal technology for any kind of surgery.

Dr. Colella: Correct. Robotic surgery competes with other very well established, very safe technologies, even in the field of vascular surgeries -- by which I mean operating on blood vessels -- it's been done and it's been done successfully. Of course, the noninvasive, percutaneous vascular procedures have been around for the better part of 10 years and have evolved into a very effective, almost perfect tool, which would be difficult for the da Vinci to replace. I know of neurosurgeons who are evaluating it and looking at its use in many of their procedures because of its precision and visual capabilities.

Medscape: Is there anything else we should know?

Dr. Colella: There is one more advantage of robotic surgery that is unique, certainly, to what I do, and I think it is going to be applicable and advantageous across many other specialties as surgeons experience this. Many surgical procedures, as you know, carry the risk for deep venous thrombosis, which on some occasions can produce life-threatening pulmonary emboli. We try to prevent these using anticoagulants, which increases the risk for bleeding. Now, using the example of gastric bypass, the robot is so efficient in allowing greater use of sutures rather than staples that the incidence of bleeding is reduced to an almost infinitesimal number. As a result, we have fewer concerns about giving anticoagulants preoperatively and so achieving the greatest impact on deep venous thrombosis reduction. Nobody ever anticipated that as being a benefit to robotic surgery. This is not directly a function of the robot, but it is closely tied to what you can accomplish by using the robot.

Another advantage that gets lost on many people who don't truly understand robotic surgery is that this is computer technology. With computers rapidly expanding in terms of their capabilities, the robot follows right along. Its potential is unlimited. It's only bound by imagination and the limitations of computer processing. Laparoscopy has completed its evolution; innovation in that technology is pretty much done.

“Is Robotic Surgery Worth Its Price? An Interview With Dr. Joseph Colella” by Carol Peckham, Medscape, Jun 20, 2013, at www.medscape.com/viewarticle/806484_5

AMA Declares Obesity a Disease by Marcia Frellick for Medscape Medical News on June 19, 2013.

Physicians voted overwhelmingly to label obesity as a disease that requires a range of interventions to advance treatment and prevention.

However, there was impassioned debate in the hours before the vote here at the American Medical Association (AMA) 2013 Annual Meeting.

Although policies adopted by the House of Delegates have no legal standing, decisions are often referenced in influencing governmental bodies. This decision could have implications for provider reimbursement, public policy, patient stigma, and International Classification of Diseases coding.

"Obesity is a pathophysiologic disease. There is a treatment for this disease; it involves behavioral modifications, medications, and surgeons. Obesity affects minorities disproportionately," said Jonathan Leffert, MD, alternate delegate for Endocrinology, Diabetes, and Metabolism. "The scientific evidence is overwhelming."

Melvyn Sterling, MD, said this brings to mind to the debate over whether hypertension is a disease.

"I'm a general internist, among other things, and I treat the complications of this disease. It's interesting to look back in history at a time when hypertension was not thought to be a disease," said Dr. Sterling, who is from the AMA Organized Medical Staff Section, but was speaking for himself. "Obesity is a disease. It's very, very, very clear that even though not every hypertensive gets a stroke and not every obese person suffers the complications, that does not change the fact that this is a disease."

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Neuroimaging may help in determining the best first-line treatment for patients with major depressive disorder (MDD), a new study suggests.

Results showed that pretreatment brain activity in the right anterior insula on positron emission tomography (PET) predicted whether depressed patients would best achieve remission with an antidepressant or cognitive-behavioral therapy (CBT).

"Our goal is to develop reliable biomarkers that match an individual patient to the treatment option most likely to be successful, while also avoiding those that will be ineffective," Helen Mayberg, MD, of Emory University in Atlanta, Georgia, who worked on the study, said in a statement.

The study, funded by the National Institutes of Health, was published online June 12 in JAMA Psychiatry.

"For the treatment of mental disorders, brain imaging remains primarily a research tool, yet these results demonstrate how it may be on the cusp of aiding in clinical decision-making," Thomas R. Insel, MD, director of the National Institute of Mental Health, who was not involved in the study, said in a statement.

Currently, determining whether a particular patient with MDD will respond best to psychotherapy or medication is based largely on trial and error, the authors note in their article. It is estimated that fewer than 40% of patients achieve remission following initial treatment.

In this report, Dr. Mayberg and colleagues suggest that they have identified a potential biomarker to help predict which type of treatment (medication or psychotherapy) will work best.

They used fluorine-18 fluorodeoxyglucose (FDG) PET to measure brain glucose metabolism at rest in a group of patients with MDD prior to random assignment to escitalopram (10 - 20 mg/day) or 16 sessions of CBT for 12 weeks.

The primary analysis was based on 38 patients with clear outcomes and usable PET scans: 12 remitters to CBT, 11 remitters to escitalopram, 9 nonresponders to CBT, and 6 nonresponders to escitalopram.

"We analyzed the baseline PET scans as a function of outcome to identify whether or not there was a discriminator between CBT remitters, drug remitters, and the nonresponders in both groups," Dr. Mayberg explained in a JAMA Psychiatry podcast.

They identified 6 limbic and cortical regions that could differentiate these 4 groups; they report that the right anterior insula showed the most robust discriminant properties across groups (effect size = 1.43).

In particular, insula hypometabolism was associated with remission to CBT and poor response to escitalopram, whereas insula hypermetabolism was associated with remission to escitalopram and poor response to CBT.

"These data suggest that insula metabolism alone (relative to each person's whole-brain mean metabolism) may serve as a pretreatment biomarker to guide initial treatment selection (medication vs CBT) for a patient presenting with a major depressive episode," the researchers say.

"If these findings are confirmed in follow-up replication studies, scans of anterior insula activity could become clinically useful to guide more effective initial treatment decisions, offering a first step towards personalized medicine measures in the treatment of major depression," Dr. Mayberg commented.

The role of the anterior insula in major depression is well established. The anterior insula is known to be important in regulating emotional states, self-awareness, decision-making, and other thinking tasks. Changes in insula activity have been observed in studies of various depression treatments, including medication, mindfulness training, vagal nerve stimulation, and deep brain stimulation.

“Neuroimaging May Predict Best Treatment for Depression” by Megan Brooks http://www.medscape.com/viewarticle/806426nlid=31776_1049&src=wnl_edit_dail&uac=198842SJ

In an effort to shine light into the murky world of hospital billing, the Centers for Medicare & Medicaid Services have released data showing how much is charged and how much Medicare paid for the 100 most commonly billed procedures in 2011 at 3,000 hospitals across the United States.

The data reveal that patients who have no one to negotiate on their behalf are more likely to be saddled with what advocates say are bloated charges, designed to be a starting point for negotiation between hospitals and private insurers, or set by Medicare.

In Palm Beach County, hospitals routinely charged six to eight times the Medicare rate, and as high as 12 times the rate.

Take a simple-sounding diagnosis, like chest pain.  Columbia Hospital (now West Palm) billed $34,109 for the treatment.  Medicare reimburses only $3,763.  A private insurer would likely pay closer to $5,000.

Or look at dizziness or vertigo.  Delray Beach Medical Center charged $41,182 to treat it.  Medicare paid $3,654, less than a 10th of the full rate.

In Palm Beach County, Columbia Hospital, Delray Medical Center, JFK, and Palms West each logged charges that were at least nine times greater than the Medicare rate.

"The patients who will get the bills for the full amounts are the uninsured, in many cases the most vulnerable in society," said Brian Cook, a CMS spokesman.

The hospital industry argues that few patients are expected to pay full charges.

Hospital billing is important because families of 54 million Americans struggle to pay medical bills, according to a report released this month by the U.S. Centers for Disease Control and Prevention, using 2012 data.

That number dropped slightly from 2011.  Analysts fear fewer people in medical debt indicates that fewer people are getting medical treatment, in part because they may not have a job or employer-sponsored health care.

In Palm Beach County, one in five residents has no health insurance, according to the county health care district.

The American Hospital Association argues there is no discrimination in billing.  Every patient is billed the same charge, regardless of whether they have insurance, said Caroline Steinberg, a vice-president at the association.

Each hospital has a master list of prices, derived from something called a chargemaster, which dictates what the hospital bills for supplies, drugs and every treatment involved in caring for a specific diagnosis.

The chargemaster represents the "kitchen sink" method of billing, said Dave Belk, a California internist who runs a site called truecostofhealthcare.org

Different insurers and the government cover costs differently, so to ensure they get paid no matter the reimbursement criteria, Belk said, hospitals pile in nay charge they think an insurance company or the government might pay. 

Medicare rates are set by the government.  Hospitals benefit because the government promises volume.  And a private insurance company with a large share of the market gets a better rate because it agrees to include a hospital in its network.

People who have insurance are not immune to the effects of the chargemaster.  If the hospital begins the negotiation with the insurance carrier at a higher price, even when the insurer haggles for a discount, it could end up paying more than if the hospital started with a lower price, said Robert Laszewski, a former health insurance executive and president of the consulting firm Health Policy and Strategy Associates.

"It's not a harmless little exercise here," he said.

Lind Quick, president of the South Florida Hospital & Healthcare Association, describes the conversation between insurers and hospitals as "wheeling and dealing, like you would do at a flea market."

The insurer argues the care costs less than the hospital is charging.  The hospital says yes, but not as little as you think.  They haggle, and the insurance company ends up agreeing to pay far less than the raw charge price, but more than Medicare pays.

The uninsured don't do as well at the health care flea market.

"They are a single buyer, so they don't have any pull," Quick said.

But the raw charges come from real costs that include everything needed to provide care: supplies, the workforce, the building's mortgage, lights, administration, cleaning crew and food service, Quick said.

"Like any business, even a not-for-profit institution has to have more revenue come in than they have go out," she said.  "They charge something over and above the cost."

Pat Palmer makes her living fighting her clients' hospital bills and other medical charges as founder of Medical Billing Advocates of America.  It is a fast-growing industry that serves uninsured clients as well as people who have plans with flimsy coverage or high deductibles that must be met before the insurer kicks in.

Palmer's clients have brought her bills that charge three times for use of the same equipment, she said.

The bill might contain $150 a minute for the use of an operating room.  The there's a separate charge for the ventilator or every piece of equipment, at least some of which ought to be covered in the room rate.

"There's no rhyme or reason for that amount," Palmer said.

Looking at the chargemaster is misleading because most patients do have insurance, and thus don't pay the full charge.  And for those who don't, hospitals often provide charity care, said the AHA's Steinberg.

A number of Palm Beach County hospitals agreed.

Among county hospitals, Delray Medical Center showed the greatest disparity between what it charges and what Medicare pays.  For at least five diagnoses, from dizziness to circulatory problems, the hospital charge was ten times higher than the Medicare reimbursement rate.

While full charges show up on the bill, the hospital cuts the price for uninsured patients close to rates paid by those with private coverage, said a spokeswoman for Tenet Healthcare, which owns Delray Medical Center.

But when asked to provide the specific uninsured rates for those five procedures in which the charges seemed particularly high, spokeswoman Shelly Weiss said she could not.

That's part of the problem for those uninsured people who need to know just how much debt they are going to assume before they can be treated.

"There's really no clear way to give you a black and white answer," Weiss said.

One reason, she said, is that a knee replacement will cost less for a healthy patient who plays tennis and is in and out of the hospital in three days.  A 90-year-old who is overweight, diabetic and requires a more complicated treatment could end up in the hospital for 20 days, she said.

"It's not you walk into a store and buy a knee replacement and it costs'X"," she said.

Medicine is more complicated that going to a grocery to buy a carton of eggs, Weiss added.

But Holly Wollack, a Miami-based advocate who helps clients negotiate medical bills, said Americans would not tolerate it if grocery shelves contained no prices above the canned goods, no scales in the produce section.

"Would you go to the supermarket and fill up a cart of groceries and then take a ticket from a scanner for 'food, paper goods, and other' and they ask you to pay $116?" she asked.  "People do it at hospitals every day."

Billing one patient more than another is nothing new.  It's among the primary arguments for buying health insurance.  The massive spread between the cost for people with insurance or Medicare and those without it, however, has raised concerns in the Obama administration.

Under the Affordable Care Act, nonprofit hospitals are no longer permitted to charge these list price fees to patients who qualify for financial assistance.

The catch, though, is that hospitals are permitted to set their own policies about who qualifies for financial help.

Patients receiving treatment at for-profit hospitals, like most in Palm Beach County, have no government safety net to keep them from being charged whatever price a hospital sets.

Some for-profit hospital chains that operate in Palm Beach County have made commitments on their own to cut rates for the uninsured.

One of my staff brought to my attention this morning that the latest issue of Real Simple magazine has a useful article on how to spot medical billing errors and a mention of FAIR Health data:

"Chances are, you don't stop to study sales receipts or read bills thoroughly before paying them.  Hey, you're busy!  But the people who prepare your bills are busy, too, and they can make mistakes.  Case in point: Up to 40 percent of medical bills may contain errors, according to Stephen Parente, a professor of health finance at the University of Minnesota, in Minneapolis.  That's why it's worth taking a few valuable seconds to scan your bills.  Here's the scoop.

How to spot it: Once you receive the Explanation of Benefits (EOB) from your health insurer, call the billing department of your doctor or hospital to request a detailed, itemized receipt.  This receipt should match your EOB; make sure it lists the correct procedure, with no double billing.  If a fee seems surprisingly high, go to FairHealthConsumer.org, a database that provides cost estimates for medical services.  A big discrepancy between your bill and the estimate could mean that you are being overcharged.

How to fight it: First address questionable charges with the billing department and your insurer.  Tell them, "This bill is not what I expected to pay for this service, and I hope you can help me look more closely at the details," suggests Erin Moaratty, a spokesperson for the non-profit Patient Advocate Foundation, in Hampton, Virginia.  If the representative can't address your concerns, ask to speak with a supervisor.  For a very steep bill consider hiring a medical advocate, who will contest the charges (find one at billadvocates.com).  Just bear in mind that you'll probably have to pay the advocate $50 to $150 an hour or a percentage of your savings; the cost can quickly add up."