The Pennsylvania Health Care Cost Containment Council (PHC4), a pioneer in publishing quality and cost data, has been able to compare charges with actual insurance payments for only two types of heart surgery. For bypass surgery, insurers paid, on average, less than one-third of charges.

A recent study by Johns Hopkins researcher Gerard Anderson found that Pennsylvania and New Jersey had the highest charges compared with payments in the nation. New Jersey hospitals charge almost four times what insurers and subscribers pay and their counterparts in Pennsylvania charge 3.5 times.

Yet charges are the numbers that callers get when they simply ask a hospital for a price. They are the numbers in PHC4's reports comparing most types of hospital treatment. New Jersey's hospital association has posted charges for many procedures.

In short, they are the numbers that the people who have the most reason to care about comparing hospital prices - the uninsured - can get most easily.

But things get even stranger. Hospitals say uninsured people rarely try to get prices in advance, although some are getting better at it. Most go to the emergency room, where hospitals are legally bound to treat them, and they take their chances with the bill. Most are then offered free or heavily discounted care, the hospitals say, and the vast majority don't even pay their discounted bills.

At Einstein, for example, about half of uninsured patients qualify for free care. The rest are asked to pay 1.5 times what Medicaid would pay for the same care. The hospital collects only 8 percent of that expense.

Anderson, who wrote a scholarly article - "From 'Soak the Rich' to 'Soak the Poor': Recent Trends in Hospital Pricing" - about the irony that the uninsured are quoted far higher prices than the insured, is not persuaded. He said some people are indeed asked to pay charges, and high medical bills are the second most common reason for personal bankruptcies. Most uninsured people are not sophisticated enough to know they can negotiate prices, and they're not in much of a position to argue anyway.

"If you don't have any insurance, you're trying to get in the door," he said. "Now you're going to negotiate a price?"

New data for negotiations

For those who do try, though, this is where some of the available data can come in handy. Medicare has started publishing what it pays individual hospitals, a number that can help patients get a better handle on what care actually costs. (Hospitals say Medicare pays slightly less than their costs.)

In the past year, Anderson said, he has helped an Amish leader in Iowa negotiate with a hospital that had charged $1.2 million for treating a premature baby. Armed with the Medicare data, the man got the bill lowered to $250,000, an amount the Amish community intends to pay.

To address this issue, New Jersey's Legislature last month passed a bill that would prohibit hospitals from charging the uninsured more than 115 percent of what Medicare would pay. It still needs the governor's signature.

Despite the obvious complexity, hospitals, insurance companies and federal and state governments are forging ahead with efforts to make price information more available.

Doylestown Hospital recently began listing a "pricing hotline" on its home page. While callers are given the list price for a service - $5,000 for a colonoscopy and $7,000 to $10,000 for a delivery - they are also referred to financial counselors to learn about discounts for the uninsured.

Ron, an uninsured man from Doylestown who did not want his full name used, called the hotline last month to ask about the price of an MRI and some blood tests. After he talked with a financial counselor, he said, the price was cut in half. "I'm perfectly content with that," he said.

Bill DiGiorgio, who directs Doylestown's program, said he also helps insured patients figure out their out-of-pocket costs in advance. "A lot of them want to know what they're getting into," he said. "A lot of them are scared."

Exploring how to make prices meaningful for insured people just takes you deeper into Pandora's box. People with set copayments have little incentive to use one doctor or hospital over another because of price. Even with plans under which subscribers pay a percentage of the bill or have deductibles of several thousand dollars, a subscriber can reach his or her out-of-pocket maximum with one hospitalization. As a result, insurers say patients so far are most interested in the prices of relatively inexpensive procedures such as diagnostic tests.

Philadelphia-based Cigna Corp. has a sophisticated Web site that lets its subscribers compare quality measures and costs at specific providers. For instance, in the Philadelphia area, contracted prices for a colonoscopy ranged from $600 to $3,700 and for a vaginal delivery from $2,600 to $8,300. During one recent month, about a fifth of subscribers with high-deductible plans who needed a colonoscopy or a place to deliver a baby checked the data.

The federal government recently expanded its hospitalcompare.hhs.gov Web site, which gives information about Medicare's payments and quality measures for specific hospitals. But it recognizes that Medicare patients still don't have much incentive to care about price. The Centers for Medicare and Medicaid Services (CMS), the agency that runs Medicare, is now piloting a program in four western states where patients will share in the program's savings when they choose hospitals that have given Medicare discounts. If, for example, a hospital agrees to accept $2,000 less from Medicare for a heart bypass, a Medicare subscriber who chose that hospital for the procedure would get a $1,000 check.