It was supposed to be a fun evening out for Katy and Michael Branson. But their daughter Lucy, who was 3 at the time, apparently had other ideas.

The couple had tickets for a Saturday night show in April in their hometown of Las Vegas and had arranged for a sitter to watch their two girls. But as Mom and Dad were getting dressed, Lucy came upstairs to their bedroom coughing and looking rather uncomfortable.

“I think she has something up her nose,” Michael said.

For reasons she couldn’t quite explain, Lucy had shoved a matching pair of pink Polly Pocket doll shoes up her nose — one in each nostril.

Her parents tried to get her to blow her nose to dislodge the plastic footwear, but Lucy could do no better than a few sniffs. Katy found a pair of tweezers and was able to remove one shoe, but the second was too far up her tiny nose for them to reach.

Michael took Lucy to a nearby urgent care center, where the doctors had no more luck with the tweezers — called forceps in medical parlance — they had on hand and suggested he take her to the emergency room. There, a doctor was able to remove the shoe in less than a second, as Michael recalled it, with a longer set of forceps. The doctor typically finds Tic Tac mints up there, he told them. This was his first doll shoe extraction.

“All in all, it was an eventful evening,” Katy said. “My husband makes it back, we go to the show, my daughter’s fine.”

The Bransons figured they had weathered another typical night of parenting and didn’t give it much more thought. Then the bill came.

The patient: Lucy Branson, now 4, a precocious girl with a fondness for any sort of doll. She is insured through her father’s high-deductible plan with UnitedHealthcare.

Total bill: $2,658.98, consisting of a $1,732 hospital bill and a $926.98 physician bill.

Service provider: St. Rose Dominican, Siena Campus, in Henderson, Nev., part of the not-for-profit Dignity Health hospital system.

Medical procedure: Removal of a foreign body in the nose, using forceps.

What gives: The Bransons negotiated a reduction of the physician’s bill by half by agreeing to pay within 20 days. But Dignity Health declined multiple requests for an interview or to explain how it arrived at the $1,732 total for the ER visit.

“Not every urgent situation is an emergency,” the hospital said in an emailed statement. “It is important for patients to understand the terms of their health insurance before seeking treatment. For example, those with high-deductible plans may want to consider urgent care centers in nonemergency situations.”

The hospital billed the Bransons $1,143 for the emergency room visit and an additional $589 for removing the shoe. The entire $1,732 hospital bill was applied against their deductible.

For public health plans like Medicare or Medicaid, the hospital generally bills an average of $526 for removing a foreign body from the nose and gets an average payment of $101, according to WellRithms, a medical billing review firm.

According to cost reports submitted to Medicare, the hospital’s average cost for the procedure comes to less than $48. That’s less than a quarter of the $222 fee WellRithms recommended and well below the $589 St. Rose charged the Bransons.

The Bransons had options as they chose their employer-sponsored health plan. They picked one with a high deductible of $6,000 per year. So instead of paying $500 more a month in premiums, the family could pocket that difference if it avoided any major health problems.

“I’d rather gamble that I might have to pay it, versus commit to paying it every month,” Katy said.

The Bransons were ready to cover the full deductible for any emergency that might arise. They just never thought something as simple as extracting a plastic shoe with tweezers would garner such a big bill.

Removing a foreign body from a child’s nose or ear is a fairly common procedure in emergency rooms, with the variety of objects removed from noses limited only by the size of the nostrils.

“Kids like to put things in their nose or their ears, for whatever reason,” said Dr. Melissa Scholes, an ear, nose and throat specialist with the University of Colorado School of Medicine.

Scholes recently reviewed records for 102 children who came to Children’s Hospital Colorado from 2007 to 2012 with objects stuck in their noses. About a third of those patients were referred to an ear, nose and throat clinic, and about half of those required surgery to remove the object. Doctors were able to remove the object in the emergency room in the remaining two-thirds of cases.

Scholes said pediatricians don’t often have the necessary tools to remove the object. Those can include extralong tweezers or a catheter with a balloon on the end. The tip of the catheter is snaked past the object, then the balloon is inflated and the catheter is pulled out, dislodging the foreign body.

“People don’t really have a good grasp of the anatomy of the nose, because a lot of people think it’s just like a tube,” Scholes said. “It’s a big cave once you get past the nostrils. So once things get back far enough, you kind of lose them.”

Resolution: The Bransons are still fighting to get a detailed explanation of how Dignity Health calculated its bill.

“It’s not even so much that we can’t pay that if we absolutely have to,” Katy said. “It doesn’t make sense that it costs that much. A human being needs to look at this and say, ‘Why are we charging $3,000 to take a Barbie shoe out of the kid’s nose?’ ”

After all, Katy doesn’t own a single pair of shoes worth anywhere close to $3,000 herself.

“Well, apparently, now I have one,” she said. “But they’re not in my closet; they’re in the playroom.”

The takeaway: Check with your doctor if you can about whether a medical issue constitutes an emergency or if it can wait until morning.

Sometimes your pediatrician’s office can recommend a do-it-yourself method for removing an object in the nose to avoid a costly emergency room visit.

Known as the “mother’s kiss,” Mom covers the child’s mouth with her mouth to form a seal, blocks the clear nostril with her finger and then blows into the mouth. The pressure from the breath may then expel the object. (The technique works equally well when performed by dads.)

For parents whose children have put things up their noses, Scholes said such objects rarely move much and can generally wait until an appointment the next morning. Having the object removed without the ER facility fee will be cheaper.

In terms of the bill, the Bransons were smart to negotiate right away, and they succeeded in getting a significant discount from the original. Many hospitals offer what they like to call “prompt-pay discounts” (often 10% to 25%). For hospitals, getting the cash quickly is valuable and even billing clerks may be able to approve the discount on the spot.

But don’t jump at the first discount they offer. And don’t let an outrageous bill sit on the kitchen table as you get angrier and angrier. Start haggling and hassling ? and keep it up. After all, a 25% percent discount off a highly inflated bill results in one that is only slightly less outrageous, as the Bransons found out the hard way.

NPR produced and edited the interview with KHN Editor-in-Chief Elisabeth Rosenthal for broadcast. Freelance reporter Stephanie O’Neill provided audio reporting.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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When Matthew Braun gets out of medical school, he’ll be able to prescribe opioids.

A decade ago, he was addicted to them.

“The first time I ever used an opioid, I felt the most confident and powerful I’d ever felt,” Braun says. “So I said, ‘This is it. I want to do this the rest of my life.’ “

Opioids took away his anxiety, his inhibitions, his depression. And they were easy to get.

“I just started breaking into houses,” Braun says. “I found it amazing how trusting people were in leaving windows open and doors unlocked, and I found a lot of prescriptions.”

Vicodin, OxyContin, tramadol. The drugs were everywhere. At the time, more than a decade ago, doctors and dentists were writing lots of prescriptions — even to Braun.

“I didn’t need 20 Vicodin when I got my wisdom teeth out,” he says. “So I just saved them.”

Braun, who hasn’t used opioids in years, is now a first-year medical student at Pacific Northwest University of Health Sciences in Yakima, Wash. He told his story at a two-day summit on opioids held in Yakima.

One goal of the event was to get past the angry rhetoric that often surfaces in discussions of opioids.

“It can get very hostile,” says Edward Bilsky, a pain researcher and the university’s provost and chief academic officer.

Bilsky has heard people in the addiction community blame chronic pain patients for opioid overdoses. The logic is that widespread use of opioids for pain has fueled addiction and abuse.

“And on the flip side,” Bilsky says, “pain groups are saying, ‘No, it’s [people in the addiction community] that abuse these drugs, and now I can’t get access to something that did give me some semblance of quality of life.’ “

Bilsky says the summit was designed to help the pain and addiction communities acknowledge common barriers — such as stigma and access to care — and encourage them to work together to find solutions.

So in addition to people like Braun, who has experienced addiction, the event included people like Katie Buckman, a third-year medical student at the university who gets severe migraines.

“It feels like your head is going to explode,” Buckman says. “And on top of that, you can’t tolerate light, and the nausea and vomiting — you’re just miserable.”

Migraines almost forced Buckman to leave medical school. But she has been able to continue with help from a primary care doctor who understands the severity of her pain.

“If I’m lucky enough to have the migraine between Monday and Friday from 8 to 5,” she says, “I can call him and get a shot of Demerol,” which is an opioid.

That’s rare, Buckman adds. Her migraines have largely disappeared since she started on a new preventive drug a few months ago. When they do crop up, her usual remedy is Benadryl and fluids.

But Buckman still remembers the stigma that pain patients can face when they show up in a hospital’s emergency department.

“One time I had a doc, before he even came in and introduced himself as my caregiver, he just popped his head in, said, ‘Well, you’re not going to be receiving any narcotics today,’ ” Buckman says.

Then there are doctors like Tom Eglin, an emergency physician who also participated in the opioid summit.

Eglin is a faculty member at the university and works at Virginia Mason Memorial hospital in Yakima. So he knows what can happen to drug users who take a powerful opioid like fentanyl thinking it’s something less potent.

“They go into respiratory arrest,” he says. “And if they’re lucky, [a first-responder] has naloxone and can reverse that.”

But Eglin also sees patients who clearly need an opioid. They may have excruciating pain from a kidney stone, a fracture or a bad burn.

“Pain is the primary reason that people come to the emergency department,” he says. “A typical night we’re always writing prescriptions for pain medications.”

The big challenge for an emergency physician is deciding whether a patient with no detectable injury is seeking drugs, Eglin says.

“Sometimes it’s obvious,” he says. “But the majority of the time, it’s not just difficult — it’s impossible.”

Disabling back pain, for example, often occurs in patients with normal X-rays and CT scans.

And maybe, Eglin says, looking for drug-seeking behavior isn’t a doctor’s most important job when someone comes to them in distress.

“I try not to make that judgment,” Eglin says. “Whether they’re addicted or whether they’re a migraine sufferer, they are still there for pain relief. And most people who are addicted still have the perception of bad pain.”

What’s frustrating, Eglin says, is that even when patients end up in the emergency room from an overdose, there’s no easy way to get them into a treatment program. “Most of the time they get discharged to the street,” he says.

People addicted to opioids and people in chronic pain have a lot in common: Both groups face stigma, often struggle to get treatment and need doctors who understand their problem.

That’s a lesson medical students Buckman and Braun have embraced.

Once she’s a doctor, Buckman says, “I’ll be able to empathize at a different level because I have experienced severe pain.”

And Braun says his own history of addiction will help him treat people with that condition.

But even someone in recovery may need an opioid for certain types of pain, he says, adding that he’d write a prescription if it were appropriate and the patient was taking active steps to avoid relapse.

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Insurance regulators across the country are taking action against a Georgia-based company that markets and administers programs on behalf of health care sharing ministries.

State officials in Texas, Colorado, Washington and most recently New Hampshire accuse Aliera, as well as Trinity HealthShare, an entity with which it contracts, of violating state and federal requirements. Those violations include failing to make its religious affiliations clear and selling plans outside the markets allowed by statute.

Members of health care sharing ministries pay monthly premiums, with the expectation that the money will be shared when medical bills arise. Though no exact figures exist, industry groups say close to 1 million Americans get their health coverage through these Christian-based entities.

“There are legitimate health care sharing ministries that offer coverage for their members, but Aliera and Trinity are not one of them,” said New Hampshire Insurance Commissioner John Elias, who accuses the companies of selling illegal insurance products.

One New Hampshire customer who signed up for Trinity’s health care sharing ministry is Keith Meehan, 49, an international rice salesman whose company doesn’t provide health insurance.

After his doctor recommended back surgery for a disk issue, Aliera and Trinity HealthShare assured Meehan the procedure didn’t require preapproval. But after the surgery, it declined to pay approximately $200,000 in medical bills, contending his back pain was a preexisting condition.

“I feel like I was sold a bad bill of goods,” Meehan says. “I had no idea.”

Health care sharing ministries don’t have to follow the same rules as insurers, and they face no requirements to pay claims. To industry watchers, their marketing materials don’t lay out these risks clearly enough.

“Having a disclaimer somewhere on Page 17 saying this is not insurance and there is no guarantee to pay is not necessarily going to turn people away,” says JoAnn Volk, a researcher at Georgetown’s Center on Health Insurance Reforms.

But to many families, health care sharing ministries offer a lower-cost alternative for coverage that also aligns with their values.

“The cost was typically a fraction, typically well under half and usually closer to a third of what the cost of conventional insurance was,” says Fenton Groen, a builder in Rochester, N.H., who has been happily enrolled in health care ministries since the early 1990s.

Along with the lower sticker price, Groen believes the popularity of health care sharing has grown in recent years because most ministries won’t cover abortion services. Many also offer prayer hotlines for members.

Groen says he supports regulators stepping in to stop a company like Aliera if, as alleged, it is not adhering to the few regulations these entities must follow.

“Given the explosive growth of health care sharing ministries, it is not surprising to me that someone would try to cut in on that,” says Groen.

Other health care sharing groups say Aliera’s actions are harming the reputation of the broader industry.

“The sharing ministries have been very alarmed, very concerned about the press reports and the misconceptions that people can have about the sharing ministries and the legitimate work they actually do,” said Dr. Dave Weldon, president of the Alliance of Health Care Sharing Ministries.

Investigative reporting by the Houston Chronicle revealed that the co-founder of Aliera, which is based in Georgia, previously served time in prison for securities fraud. The company is facing a proposed class-action lawsuit in Washington state for alleged deceptive practices.

Aliera and Trinity both deny violating New Hampshire law. Aliera says it plans to appeal the cease-and-desist order.

“Aliera will continue to vigorously defend against false claims made about the administrative, marketing and other support services we provide to health care sharing ministries (HCSMs), and we’re confident the HCSMs we support will defend the right of their members to exercise their religious convictions in making health care choices,” wrote the company in a statement.

Meehan, the rice salesman with $200,000 in unpaid medical bills, says he wishes he had read the fine print before signing up.

“I mean, I’m not trying to skate on my responsibilities,” he says. “Had I known that this was the way it was going to turn out, I would have suffered. I can endure some pain, both physical and mental. But I would have never gone through with the surgery.”

More pain is on the way. Meehan says he is considering filing for bankruptcy.

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When Lorraine Griggs’ 86-year-old father was diagnosed with prostate cancer, he was treated with 35 rounds of radiation, though he had a long list of other serious medical issues, including diabetes, kidney disease and high blood pressure. The treatment left him frailer, Griggs recalls.

A few years later, when his prostate cancer reoccurred, Griggs’ father received a different kind of cancer care. Before his doctor devised a treatment plan, she ordered what’s known as a geriatric assessment. It included a complete physical and medical history, an evaluation by a physical therapist, a psychological assessment and a cognitive exam. The doctor also asked her father about his social activities, which included driving to lunch with friends and grocery shopping with some assistance.

“When the doctor saw how physically active and mentally sharp my father was at 89 years of age, but that he had several chronic, serious medical problems, including end stage kidney disease, she didn’t advise him to have aggressive treatment like the first time around,” says Griggs, who lives in Rochester, N.Y.

Instead, his oncologist placed her dad on one pill a day that just slowed down his cancer. Griggs’ father was able to enjoy his activities for another three years until he died at the age of 92.

Geriatric assessment is an approach that clinicians use to evaluate their elderly patients’ overall health status and to help them choose treatment appropriate to their age and condition. The assessment includes questionnaires and tests to gauge the patients’ physical, mental and functional capacity, taking into account their social lives, daily activities and goals.

The tool can play an important role in cancer care, according to clinicians who work with the elderly. It can be tricky to predict who will be cured, who will relapse and who will die from cancer treatment. Geriatric assessments can help physicians better estimate who will likely develop chemotherapy toxicities and other serious potential complications of cancer treatment, including death.

Geriatric assessment includes an evaluation by a physical therapist, a psychological assessment, a cognitive exam and a complete physical and medical history. The doctor takes all these factors into account and tallies a score for their patient to help guide their decision-making about the patient’s treatment.

Although the geriatric assessment is not 100% accurate, “it’s better than the clinician eyeball test,” says Supriya Gupta Mohile, a geriatric oncologist and professor of medicine at the University of Rochester. “If I didn’t do a geriatric assessment and just looked at a patient I wouldn’t have the same information,” she says.

A vulnerable population

More than 60% of cancers in the U.S. occur in people older than 65. As the population grows older, so will the rate of cancer among seniors. The cancer incidence in the elderly is expected to rise 67% from 2010 to 2030, according to a 2017 study in the Journal of Clinical Oncology. Yet many oncologists don’t have geriatric training.

Mohile, who treated Griggs’ father during his cancer relapse, explains that geriatric oncologists take a different approach than many other oncologists.

“We want to help older adults successfully undergo cancer treatment without significant toxicities, so it leads to a survival benefit,” she says. “What we don’t want to do is treat patients who will be harmed.”

Mohile says when she saw that Griggs’ dad was frail because of his other health issues, she explained that the standard treatment of care would be difficult for him.

“We went through the decision-making together and I was able to explain how it could cause harm and it would have no risk benefit. He wanted to live and not suffer toxicities,” she says.

A growing body of evidence supports the notion that cancer care for older adults can be improved with geriatric assessments.

A study published in the Journal of Geriatric Oncology in November found that in 197 cancer patients 70 years and older, 27% of the treatment recommendations patients received from the tumor board were different from those received after completing a geriatric assessment. Patients who received a geriatric assessment were recommended to have less intensive treatment or palliative care.

Overall, geriatric assessments have been found valuable for helping older adults with health conditions achieve higher quality of life. A 2017 Cochrane review of 29 studies of geriatric assessments on patients who’d been hospitalized found that patients were more likely to be alive and at home a year later compared to those who had standard care.

One of the reasons geriatric assessments can be so useful to clinicians treating cancer is that doctors don’t have enough information at their fingertips about how older patients respond to the drugs commonly used for chemotherapy. This is partly because there’s less research on this age group.

“You’re playing a guessing game most of the time. Older patients on chemo can get in more trouble than younger patients. The real issue is the patient’s capacity to tolerate care. I think geriatric assessments can improve how we tailor therapy,” says Efrat Dotan, associate professor of hematology/oncology at Fox Chase Cancer Center in Philadelphia and chair of the National Comprehensive Cancer Network, NCCN.

But other experts caution that geriatric assessments can backfire because of a dominant culture in medicine that tends to try to cure patients at all costs, even when treatments may be dangerous.

“Sometimes you don’t want to ask questions because you’re afraid you may have to deal with the answers,” says Otis Brawley, Bloomberg distinguished professor of oncology and epidemiology at Johns Hopkins University in Baltimore.

“The test tends to give us answers that scare us from treatment, and we are supposed to treat patients,” he says.

Often, if a cancer patient is turned away from treatment, they try to find a doctor that will offer it anyway.

“This happens all the time. The irony is that by going away from a doctor really doing the appropriate thing and then going to another doctor who doesn’t do the appropriate thing, sometimes that second doctor is actually hastening death,” says Brawley, former chief medical and scientific officer at the American Cancer Society.

An underutilized tool

Though geriatric assessments were developed about two decades ago and hailed as one of the clinical cancer advances of 2012 by the American Society of Clinical Oncology, they are still not widely used by oncologists.

The Surgical Task Force at the International Society of Geriatric Oncology found that only 6.4% of surgeons use comprehensive geriatric assessments in daily practice, and only 36.3% collaborate with geriatricians, according to a 2016 study in the European Journal of Surgical Oncology.

Many major academic centers have adopted the use of geriatric assessments. However, they’re still fairly scarce in community practices where staffing shortages, financial constraints, lack of institutional support and technology are major barriers to use. They are also time-consuming to complete — taking about two hours.

But these days, “the geriatric assessment is a tool anyone can print out and use,” Mohile says. It’s recently been streamlined and will soon be built into the online health record, EPIC, she says.

Still, lack of training among oncologists is an issue, Mohile says.

“Geriatric assessments have been around for a long time, but they have not been traditionally used by oncologists because they haven’t been trained how to do it or use it,” she says.

Finding treatment options for frail patients

Matthew LoBiondo Sr. from Conesus, N.Y., was being treated with chemotherapy for a gastrointestinal tumor when Mohile first met him as an inpatient. The 89-year-old was hospitalized because he was weak, dehydrated and not eating. Mohile says the dose of the medication he was on was too toxic for him.

Once she took over his care, she weaned him off that treatment, did a geriatric assessment with him and tailored a less toxic treatment plan.

One of the tenets of geriatric assessments is to help physicians select treatments that are best suited for a patient by getting to the core of their physical and mental capacity, regardless of their chronological age.

That’s ultimately the best way to treat older cancer patients, says Armin Shahrokni, a geriatrician and medical oncologist at Memorial Sloan Kettering Cancer Center in New York.

“The data are clear that the fitness of an older cancer patient, rather than age per se, should be the factor considered” when it comes to cancer treatment, he wrote in an editorial in the Annals of Surgical Oncology.

“Age is a meaningless number. I can see a very active 85-year-old very healthy cancer patient who runs marathons. I can also see a 65-year-old with a lot of other comorbid illnesses who is not as functional. How I treat them for cancer would be different,” Shahrokni says.

When he assesses a patient to be too frail for cancer surgery, he says it doesn’t mean that a patient would automatically go on palliative care.

“You would be amazed at how many other options open,” he says.

A frail patient with lung cancer, for instance, can be redirected from surgery to radiation, which is less toxic than chemotherapy and less invasive than surgery.

Geriatric assessments are a way to guide better cancer decision-making, he says.

As more studies about the value of geriatric assessments come out, Shahrokni says he hopes more people will become aware of their importance and find a way to implement them in their practice.

Health problems are less obvious among older adults because of atypical presentations, or because of communication problems due to hearing loss or cognitive impairment. Problems such as psychosocial status, or the environment, increase in importance in older patients because they frequently coexist with health problems and can interfere with their management.

“I think things are moving forward very nicely. In the next 10 years my hope is that not only surgeons and oncologists will do these types of assessments, but patients and their families will demand the health care system to provide a more comprehensive assessment of their functional status before cancer treatment. I think this is going to lead to better outcomes for patients,” Shahrokni says.

Cheryl Platzman Weinstock is an award-winning health and science journalist. This article was written with the support of a fellowship from the Gerontological Society of America, Journalists Network on Generations and the Retirement Research Foundation.

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