In Florida, Gov. Ron DeSantis signed a bill last week that, if federal authorities give it their go-ahead — still a very big if — would allow his state to import prescription drugs from Canada. That makes Florida the third state to pass such a law, joining Vermont and Colorado. More such legislative attempts are in the works.

“There have been 27 different bills proposed across the country this year,” says Trish Riley, the executive director of the National Academy for State Health Policy. “I think that it’s an approach that makes sense to states. It’s something they can do now to help their citizens.”

The Trump administration has made bringing down the price of prescription drugs a priority, and politicians at every level are looking for ways to make that happen.

Riley says her group didn’t help write the Florida plan, although it met with staff and provided resources and model legislation.

“States are very much frustrated by the incredibly high costs of drugs,” she says. “When you’re a state and you have to balance a budget and you pay for so much prescription drugs through your state employee plan, your municipal workers [and] through Medicaid, the cost of drugs really is front and center. So I think this is very much a bipartisan issue of urgency at the state level.”

Prescription drugs are often significantly cheaper outside the United States.

“Canada negotiates drug prices just like many other countries around the world,” explains Rachel Sachs, a law professor at Washington University in St. Louis who studies prescription drug pricing. “In the U.S., we’ve constructed a system where pharmaceutical companies are able to charge far higher prices because there’s no mechanism to push back — there’s no way to say, ‘We’re not going to pay for that drug unless we get it at a better price.’ “

So what exactly is Florida’s plan to import certain drugs from Canada, and how would it work?

The Florida law imagines negotiating with the federal Department of Health and Human Services to establish a pilot program to buy these medications from Canada in bulk. “The state would contract with a wholesaler in Canada, who would provide certain high-cost drugs that the state identifies to a wholesaler in Florida,” Riley explains.

So Floridian patients who have a prescription for one of those drugs would just go to their pharmacy and pick up their medicine as usual — all the importing from Canada would be happening in the background.

The law wouldn’t set up a way for Floridians to order medicines from Canadian online pharmacies themselves or enable them to drive north across the border to get a deal on the drugs. Rather, it’s a big-scale, institutional kind of plan.

Would Floridians even notice that their drugs were coming from Canada under this plan?

“It’s possible that the ability to purchase drugs for lower prices at the wholesale level translates into lower premiums overall for particular classes of patients or lower prices at the pharmacy for other patients,” says Sachs. “But without more details about the plan, it’s hard to know.”

And before Florida’s plan can become a reality, it still needs to clear some major hurdles.

First, the state needs to work out a lot of details — such as which Floridians and which drugs the plan would apply to.

The next hurdle is a big one: The plan needs to get approved by the federal secretary of health and human services, Alex Azar. Though the authority of the secretary to make such an approval has existed since 2003, no secretary has ever exercised that right. To win approval, Florida needs to show that the drugs it wants to import are safe and that the plan will save the state money.

On the safety front, Azar last year cited safety concerns when he, at least initially, dismissed the idea of importing drugs from Canada as a “gimmick,” in a meeting at HHS headquarters with the media and others.

“The last four FDA commissioners have said there is no effective way to ensure drugs coming from Canada really are coming from Canada, rather than being routed from, say, a counterfeit factory in China,” Azar said. “The United States has the safest regulatory system in the world. The last thing we need is [to have] open borders for unsafe drugs, in search of savings that cannot be safely achieved.”

A pharmaceutical industry group also has been running ads in Florida recently, talking about the dangers of counterfeit drugs. Riley, of the National Academy for State Health Policy, says those sorts of ads are misleading.

“I’ve seen those in every state we’re working in,” Riley says. “In fact, this program follows current FDA rules. It will use FDA-registered wholesalers. It will simply follow that same supply chain, those same protections, those same assurances of safety.”

Azar also said in that May 2018 speech that he doubted that importing Canadian drugs would save U.S. states or patients money.

“[This idea] has been assessed multiple times by the Congressional Budget Office, and CBO has said it would have no meaningful effect,” he said. “One of the main reasons is that Canada’s drug market is simply too small to bring down prices here. They are a lovely neighbor to the north, but they’re a small one. Canada simply doesn’t have enough drugs to sell them to us for less money, and drug companies won’t sell Canada or Europe more, just to have them imported here.”

Since those remarks last year, President Trump has urged Azar to work with Florida on its plan.

“President Trump and Secretary Azar are firmly committed to getting drug prices down,” HHS spokesperson Caitlin Oakley told NPR in a written statement. “They are both very open to the importation of prescription drugs as long as it can be done safely and can deliver real results for American patients.”

Of course, even if Azar has a change of heart, Florida would face another potential obstacle: getting Canadians and pharmaceutical companies to go along with the plan.

“They need to find willing suppliers for each of the drugs they’re aiming to import, and that may be more of a challenge than they anticipate right now,” says Sachs, the law professor.

Pharmaceutical companies won’t be inclined to cooperate, she says.

“They’ll lose money — if it works,” explains Sachs. “There are many things they could do all along the supply chain to ensure that drugs aren’t diverted to the U.S. in the way that Florida wants.”

Canada isn’t enthused about the idea either, Sachs says, because Florida’s laws could indirectly drive up the price of some drugs in Canada.

When you talk about importing “Canadian drugs,” points out Steve Morgan, a professor of health policy at the University of British Columbia, you’re not actually talking about drugs made in Canada or otherwise especially Canadian. “They’re not actually Canadian drugs,” he says. “They are just international medicines, manufactured typically at one or two plants worldwide to supply the entire market with a particular drug.”

If Florida’s Canadian drug importation plan were in place, Morgan says, “given the scale of manufacturing in the United States, if you were buying a drug made by and sold by an American pharmaceutical company, it’s likely you’re literally buying the same product shipped to Canada and then shipped back into the United States.”

So are Canadians worried that all 21.3 million Floridians are coming for their cheaper drugs? Not really, according to Morgan.

“Canadians feel that the policy is probably not going to result in millions and millions of Americans suddenly getting their drugs from Canada,” he says.

“As a consequence of the money to be made by way of being a middleman in the United States, I don’t think you’re going to see institutional purchasers suddenly shopping in Canada,” Morgan adds. “They will be able to get better prices by negotiating continuous discounts right there in the United States.”

And maybe that’s the point.

Just before Florida’s governor signed the bill last week at The Villages, a large retirement community outside Orlando, he said the law was already making a difference.

“It’s interesting,” DeSantis told a room full of Florida seniors who had been invited to witness the signing of the drug bill. “Since we’ve passed this bill, some of the American companies have already come to us saying, ‘Hey, we’re willing to deal and give you better prices’ — already, just for the fact that we have this.”

The room broke into applause.

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Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.

Senate Bill 1264 is bipartisan legislation that removes patients from the middle of disputes between a health insurance company and a hospital or other medical provider.

“We wanted to try to take the patients — get them out of the middle of it — because really it’s not their fight,” says Republican state Sen. Kelly Hancock, the bill’s author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out of network. It also happens if a patient goes to an in-network hospital and the patient’s doctors or medical providers are not in network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care, and patients end up with a hefty medical bill.

Consumer advocates in the state have been urging lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a bill for $108,951.

Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the media. Last summer, Drew Calver told his story to the Bill of the Month investigation from NPR and Kaiser Health News. Shortly afterward, his bill was slashed to just $332. Erin Calver says she has seen her family’s story strike a chord.

“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she says.

Drew Calver says it’s something lots of people worry about.

“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah, that could happen to me too!’ ” Drew Calver says.

In fact, getting a steep hospital bill is something more Americans say is their biggest financial fear.

“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” says Stacey Pogue of the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — more than the percentage who worry about prescription drug costs or basic necessities such as rent, food and gas.

Pogue says that’s a big reason lawmakers in the state took the issue seriously and passed legislation that she says is now one of the strongest state protections she has seen.

“It is as strong or stronger than any of the protections in the country,” Pogue says.

In addition to Texas, nearby states Colorado and New Mexico also passed legislation this year to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found that about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections, similar to those just passed in Texas.

Texas’s new surprise-bill law officially goes into effect on Sept. 1, 2020.

Hancock, the state senator, says the fight over who pays disputed bills will be back where it belongs: with insurance companies and the hospitals, doctors and labs providing medical care.

When a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.

“There is still the ability to negotiate,” Hancock says. “You didn’t have government determining what the price was or determining what the settlement was.”

But not all Texans will be protected by the new law, which does not apply to people who have federally regulated plans. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.

In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, the family switched to his wife Erin’s health plan, which will be subject to these new protections.

Pogue says people around the U.S. who have federally regulated health plans will be protected only if Congress acts. She thinks the state action will spur federal lawmakers.

“And I think Texas passing a bill will really help on that front,” she says, nothing that several other states have created similar laws. “Every nudge like that is going to help Congress move.”

Texas lawmakers did, however, pass separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of whatever health insurance plan the person has.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. Also, President Trump recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing throughout the country.

During a U.S. House Ways and Means health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The subcommittee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”

This story is part of NPR’s reporting partnership with KUT and Kaiser Health News, an editorially independent news service of the Kaiser Family Foundation. You can follow Ashley Lopez on Twitter: @AshLopezRadio.

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Dr. Louise Aronson says the U.S. doesn’t have nearly enough geriatricians — physicians devoted to the health and care of older people: “There may be maybe six or seven thousand geriatricians,” she says. “Compare that to the membership of the pediatric society, which is about 70,000.”

Aronson is a geriatrician and a professor of medicine at the University of California, San Francisco. She notes that older adults make up a much larger percentage of hospital stays than their pediatric counterparts. The result, she says, is that many geriatricians wind up focusing on “the oldest and the frailest” — rather than concentrating on healthy aging.

Aronson sees geriatrics as a specialty that should adapt and change with each patient. “My youngest patient has been 60 and my oldest 111, so we’re really talking a half-century there,” she says. “I need to be a different sort of doctor for people at different ages and phases of old age.”

She writes about changing approaches to elder health care and end-of-life care in her new book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.

Interview highlights

On how people’s health needs become more complicated as they age

While old age itself is not a disease, it does increase vulnerability to disease. So it’s the very rare person over age 60 … and certainly over age 80, that doesn’t tend to have several health conditions already. So when something new comes up, it’s not only the new symptoms of potentially a new disease, but it’s in the context of an older body of the other diseases, of the treatments for the other diseases.

If somebody comes in with symptoms and they’re an older person, we do sometimes find that single unifying diagnosis, but that’s actually the exception. If we’re being careful, we more likely find something new and maybe a few other things. We add to a list [and], we end up with a larger list, not a smaller one, if we’re really paying attention to everything going on in that person’s life and with their health.

On how the immune system changes with age

Our immune system has multiple different layers of protection for us. And there are biological changes in all of those layers, and sometimes it’s about the number of cells that are able to come to our defense, if we have an infection of some kind. Sometimes it’s about literally the immune reaction. So we know, for example, that responses to vaccines tend to decline with age, and sometimes the immunity that people mount is less. It also tends to last less long. And that’s just about the strength of the immune response, which changes in a variety of ways. But our immune system is part and parcel of every other organ system in our body, and so it increases our vulnerability as we get older across body systems.

On the importance of vaccines for older people

Older people … are among the populations (also very young children) to be hospitalized or to die as a result of the flu. The flu vaccine, particularly in a good year, but even when the match isn’t perfect in a given year, [protects] older people from getting that sick and from ending up in the hospital and from dying. … That said, we have not optimized vaccines for older adults the way we have for other age groups. So if you look, for example, at the Centers for Disease Control’s recommendations about vaccinations, you will see that there are, I believe, it’s 17 categories for children, different substages of childhood for which they have different recommendations, and five stages for adulthood. But the people over age 65 are lumped in a single category. … We’re all different throughout our life spans, and we need to target our interventions to all of us, not just to certain segments of the population, namely children and adults, leaving elders out.

On how medications can change in how they affect the patient over time

Researchers have traditionally said, “Well, we’re not going to include older people in our studies because their bodies are different and/or because they have other ailments that might interfere with their reaction to this medicine.” But then they give the medicine to those same older people … and so very frequently with a new medicine we will see all sorts of drug reactions that are not listed on the warnings. So message number one is just because it’s not listed doesn’t mean it’s not the culprit. Another key point is really any medicine can do this. And it can do it even if the person has been on it a long time. … We think of medicines as sort of fixed entities, but in fact what really matters is the interaction between the medication and the person. So even if the medication stays the same, the person may be changing.

On the importance of doing house calls in her work

What got me into medicine and what keeps me there is the people. And when you do a house call, you see the person in their environment, so they get to be a person first and a patient second, which I love. I also can see their living conditions, and more and more we’re realizing and paying attention to how much these social factors really influence people’s health and risk for good or bad outcomes.

Roberta Shorrock and Seth Kelley produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for Shots.

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In the 25 years since she snorted her first line of methamphetamine at a club in San Francisco, Kim has redefined “normal” many times. At first, she says, it seemed like meth brought her back to her true self — the person she was before her parents divorced, and before her stepfather moved in.

“I felt normal when I first did it, like, ‘Oh! There I am,’ ” she says.

Kim is 47 now and has been chasing “normal” her entire adult life. That chase has brought her to some dark places, so we agreed not to use her last name, at her request. For a long time, meth, known commonly as speed, was Kim’s drug of choice.

Then she added heroin to the mix. She tried it for the first time while she was in treatment for meth.

“That put me on a nine-year run of using heroin,” Kim says. “And I thought, ‘Oh, heroin’s great. I don’t do speed anymore.’ To me, it saved me from the tweaker-ness,” she says, referring to the agitation and paranoia many meth users experience, and how heroin, an opiate, calmed that.

Now, Kim has just finished addiction treatment for both drugs.

She was part of the last meth wave of the ’90s, and now she’s part of a new meth epidemic sweeping through parts of the United States, especially the West. Deaths involving methamphetamine are up. Hospitalizations are up.

Taking meth and opioids for a “synergistic high”

Researchers who have tracked drug use for decades believe the new meth crisis got a kick-start from the opioid epidemic.

“There is absolutely an association,” says Dr. Phillip Coffin, director of substance use research at the San Francisco Department of Public Health.

Across the U.S., more and more opioid users say they use methamphetamine as well, up from 19% in 2011 to 34% in 2017, according to a study published in the journal Drug and Alcohol Dependence last year. The greatest increases were in the western United States.

That research suggests that efforts to get doctors to cut down on writing opioid prescriptions may have driven some users to buy meth on the street instead.

“Methamphetamine served as an opioid substitute, provided a synergistic high, and balanced out the effects of opioids so one could function ‘normally,’ ” the researchers write.

It’s kind of like having a cup of coffee in the morning to wake up and a glass of wine in the evening to wind down — or using meth on Monday to get to work and heroin on Friday to ease into the weekend.

Amelia says that’s how her drug use evolved to include meth.

At first, drugs were just a fun thing she would do on the weekend — ecstasy and cocaine with her friends. Then, on Monday, Amelia would just go about her workweek.

“I’m a horse trainer, so I worked really hard, but I also partied really hard,” she says.

Then one weekend, when Amelia was feeling kind of hungover from the night before, a friend passed her a pipe and said it was opium.

“I thought it was like smoking weed or hash, you know?,” Amelia says now. “I just thought it was like that.”

She says she grew to like the opium stuff and eventually contacted the friend’s dealer.

“The woman said, ‘How long have you been doing heroin for?’ and my jaw nearly hit the ground,” Amelia says. “I was just really, honestly, shocked. I was like, ‘What? I’ve been doing heroin this whole time?’ I felt really naive, really stupid for not even putting the two together.”

Pretty soon, Amelia started feeling sick around the same time every day. It was withdrawal symptoms — a clear sign she was becoming dependent on the drug. Her weekend smoke became her daily morning smoke. Then it was part of her lunchtime routine.

“I just kind of surrendered to that and decided, ‘Screw it,’ ” she says. “I’ll just keep doing it. I’m obviously still working, I’m fine.’ “

A heroin habit is expensive. Amelia was working six days a week to pay for it. Any horses that needed to be ridden, any lessons that needed to be taught, she said yes to because she wanted the money.

But bankrolling her heroin use was exhausting. One day, one of the women she worked with at the horse barn offered her some meth as a pick-me-up.

Meth is comparatively cheap these days. It became the thing that kept Amelia going so she could earn enough money to buy heroin.

“The heroin was the most expensive part,” she says. “That was $200 a day at one point. And the meth was $150 a week.”

This pattern lasted for three years, until Amelia discovered she was pregnant. As soon as her daughter was born, she entered a residential treatment program in San Francisco — the Epiphany Center — that would accept her and her baby.

“I was OK with being a drug addict,” Amelia says. “I was OK with that being my life.” she says. “But I wasn’t OK with having kids and letting that be part of my life.”

Rehab admissions on the rise for mixers of heroin and meth

Admissions to drug rehabilitation for heroin have remained steady in recent years in San Francisco. But the number of heroin addicts reporting methamphetamine as a secondary substance problem has been rising. In 2014, 14% of heroin users entering rehab in San Francisco said meth was also a problem. Three years later, 22% said meth was also a problem.

“That is very high,” says Dr. DanCiccarone, a professor of family community medicine at the University of California, San Francisco, who has been studying heroin for almost 20 years. “That’s alarming and new and intriguing and needs to be explored.”

The speedball — heroin plus cocaine — is a classic combination, he says.

“It’s like peanut butter cups, right — chocolate and peanut butter together,” he says. “Methamphetamine and heroin are an unusual combination.”

The meth and heroin combo is colloquially referred to as a goofball, Ciccarone adds, because it makes the user feel “a little bit silly and a little bit blissful.”

For Kim, the methamphetamine use came first. Then she added heroin.

“I ended up doing both at the same time every day, both of them,” she says.

For Kim, it was always about finding the recipe to what felt normal. Start with meth. Add some heroin. Touch up the speed.

“You’re like a chemist with your own body,” she says. “You’re balancing, trying to figure out your own prescription to how to make you feel good.”

Now Kim is trying to find that balance without drugs. She’s been sober for a year. So has Amelia, the horse trainer. Her sober anniversary is the same as her daughter’s birthday.

This story is part of NPR’s health reporting collaboration with KQED and Kaiser Health News.

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Spinal surgery made it possible for Liv Cannon to plant her first vegetable garden.

“It’s a lot of bending over and lifting the wheelbarrow and putting stakes in the ground,” the 26-year-old says as she surveys the tomatillos, cherry tomatoes and eggplants growing in raised beds behind her house in Austin, Texas. “And none of that I could ever do before.”

For the first 24 years of her life, Cannon’s activities were limited by chronic pain and muscle weakness.

“There was a lot of pain in my legs, which I can now recognize as nerve pain,” she says. “There was a lot of pain in my back, which I thought was, you know, just something everybody lived with.”

Cannon saw lots of doctors over the years. But they couldn’t explain what was going on. She’d pretty much given up on finding an answer for her pain until her fiancé, Cole Chiumento, pushed her to try one more time.

“It never improved. It never got better,” Chiumento says. “That just didn’t sound right to me.”

So Cannon went to a specialist who ordered a scan of her spine. A few days later, her phone rang.

“We found something on your MRI,” a voice said.

The images showed that Cannon had been born with diastematomyelia, a rare disorder related to spina bifida. It causes the spinal cord to split in two.

In Cannon’s case, the disorder also led to a tumor that trapped her spinal cord, causing it to stretch as she grew.

In December 2017, a neurosurgeon opened up her spinal column and operated for several hours, freeing the cord.

“I think it was Day 3 after my surgery I could feel the difference,” Cannon says. “There was just a pain that wasn’t there anymore.”

As she recovered, Cannon saw lots of huge medical bills go by. They were all covered by her insurance plan. Almost a year went by after the operation.

Then a new bill came.

Patient: Liv Cannon, 26, of Austin, Texas. At the time of her surgery, she was a graduate student insured with Blue Cross and Blue Shield of Texas through her job at the University of Texas.

Total bill: $94,031 for neuromonitoring services. The bill was submitted to Blue Cross and Blue Shield of Texas, which covered $815.69 of the amount and informed her she was responsible for the balance. The insurer covered all of Cannon’s other medical bills, which came to more than $100,000, including those from the hospital, surgeon and anesthesiologist.

Service provider: Traxx Medical Holdings LLC, an Austin company that provides neuromonitoring during spinal surgery. Neuromonitoring uses electrical signals to detect when a surgeon is causing damage to nerves.

Medical service: Cannon was born with a rare spinal condition that had caused chronic pain and muscle weakness since she was a child. In December 2017, she had successful spinal surgery to correct the problem. Her surgeon requested neuromonitoring during the operation.

What gives: Neuromonitoring made sense for the type of surgery Cannon had. The bill did not. Cannon should have been warned long before her surgery that the neuromonitoring company would be an out-of-network provider whose fees might not be covered by her insurer.

At first, she was baffled by the billing information that Blue Cross sent her. “It was one of those things from the insurance company that says this is the amount we cover and this is the amount you might owe your provider,” she says.

The statement listed four separate charges from the day of her surgery. Each was described as a “diagnostic medical exam.” Together, they came to $94,031.

Blue Cross said the covered amount was $815.69 — minus a $750 deductible and $26.27 for coinsurance — and informed Cannon she might have to pay the balance — $93,991.58

“I was shocked,” she says. Chiumento was outraged.

“As soon as I saw that, I thought it was a scam,” he says.

The bill had come from an Austin company called Traxx Medical Holdings LLC. Traxx did not respond to emails, phone calls and a fax seeking comment on the charge.

The company’s website shows that Traxx provides a service called intraoperative neurophysiological monitoring, which evaluates the function of nerves during surgery. The goal is to help a surgeon avoid causing permanent damage to the nervous system.

There is an ongoing debate about whether neuromonitoring is needed for all spinal surgery. But it is standard for a complicated operation like the one Cannon had, says Richard Vogel, president of the American Society of Neurophysiological Monitoring.

On the other hand, a $94,000 charge for the service can’t be justified, Vogel says.

“You’re not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring,” Vogel says.

Most neuromonitoring companies charge reasonable fees for a valuable service and are upfront about their ownership and financial arrangements, he says. But some companies are greedy and submit huge bills to an insurance company, hoping they won’t be challenged, he adds.

Even worse, “some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons,” Vogel says.

Last year, Vogel’s group published a position statement condemning these “kickback arrangements” and other unethical business practices.

It is unclear whether Traxx, the company that provided neuromonitoring for Cannon, has any financial arrangements with surgeons. Cannon’s surgeon did not respond to requests for comment.

The size of the fee for Cannon’s neuromonitoring was only part of the problem. The other part was that Traxx — unlike her hospital, surgeon and anesthesiologist — had no contract with Blue Cross and Blue Shield of Texas.

As an out-of-network provider, the company could set its own fees and try to collect from Cannon any amount it didn’t get from her insurer.

Blue Cross and Blue Shield of Texas said it doesn’t comment on problems affecting individual members. But the insurer did offer a general statement by email about the problem:

“Unfortunately, non-contracted providers can expose our members to significantly greater out-of-pocket costs. These charges often have no connection to underlying market prices, costs or quality. If given the opportunity, we will try to negotiate with the provider to reduce the cost.”

One thing working against Cannon is that she is pretty sure that just before surgery, she signed a paper that authorized the out-of-network neuromonitoring.

“It was 4:30 in the morning and you’re like, ‘OK, let’s get this over with,’ ” she recalls.

Getting consent in the hospital may be legal, but it’s not reasonable, says Dr. Arthur Garson Jr., who directs the Health Policy Institute at the Texas Medical Center in Houston.

For example, a patient might be having a heart attack, Garson says. “You got chest pain, you’re sweating, sick as you can be, and they hand you a piece of paper and they say, ‘Sign here.’ “

The Texas Legislature passed a bill in May to protect patients from the sky-high bills this practice can produce. And Congress is considering similar legislation.

These are small steps in the right direction, Garson says.

“Asking the individual patient to make that decision even when they’re not sick, I think, is difficult,” he says, “and maybe we ought to think of some better way to do it.”

The Texas legislation is expected to take effect later this year but affects only bills that occur after it becomes law. So that $94,000 figure is never far from Cannon’s mind, even as she and Chiumento plan their wedding.

“Every time I go out and I collect the mail, I’m wondering, ‘Is this the day it’s going to show up and we’re going to have to deal with this?’ ” she says.

The takeaway: Neuromonitoring during complex surgery involving the spine can help prevent inadvertent damage. But monitoring may be unnecessary for lower-risk back operations, like spinal fusion.

It is strange that neuromonitoring is charged as a separate service, rather than part of the spine surgery. Cardiac monitoring is not charged separately during bypass surgery, for example.

When considering spine surgery, ask your doctor whether neuromonitoring will be part of the procedure. If so, will it be billed separately? Try to find out the name of the provider and get an estimate of the cost beforehand.

Check with your insurer to determine if the neuromonitoring provider is within your network and to make sure the estimated charge will be covered.

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