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He went in for a colonoscopy. The hospital charged $19,000 for two.
Tom Contos is an avid runner. When he started experiencing rectal bleeding in March, he thought exercise could be the cause and tried to ignore it. But he became increasingly worried when the bleeding continued for weeks.
The Chicago health care consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least partly because Contos, 45, has a family history of colon issues.
“I work out a lot,” he said. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, let’s get you in.'”
Northwestern Memorial Hospital asked him to prepay $1,000 out-of-pocket, and he underwent the procedure in June.
Then the bill came.
The medical procedure
Colonoscopies are performed in the United States more than 15 million times a year. Rates of colorectal cancer are on the rise, particularly among younger people.
The procedure, which is also a recommended screening for people 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.
It typically takes less than one hour, with another hour spent taking the patient’s history, administering anesthesia, and monitoring their recovery, said Glenn Littenberg, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
According to Contos’ medical record, the gastroenterologist who performed his colonoscopy described it as “not difficult.” He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.
The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.
The final bill
The hospital charged a total of $19,206 for the procedure, including physician fees. The insurer negotiated the price to $5,816 and paid $1,979, leaving a patient share of $4,047. (It wasn’t clear why the payments added up to slightly more than the negotiated price.) After Contos had paid $1,000 up front, plus $1,381 right after the procedure, the hospital said he still owed $1,666.
The billing problem: Colonoscopies that find polyps cost more
Contos was shocked and angry when he received his itemized bill. “I said, ‘I don’t understand this.’ Then I started to research the cost.”
He asked the hospital what it charges for a diagnostic colonoscopy and was told he’d been sent a cost estimate through his online patient portal prior to the procedure.
The estimate, which took his deductible of $3,200 into account, listed a total price of $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were nearly three times the estimate and why his out-of-pocket share was nearly twice as high.
One big reason was revealed in an explanation of benefits (EOB) statement from Contos’ insurance company, Aetna: Northwestern had charged for two colonoscopies, at $5,466 each. And there were two fees for the gastroenterologist — $1,535 and $1,291.
The first procedure was listed as “colonoscopy and biopsy,” while the second was listed as “colonoscopy w/lesion removal.” Aetna’s negotiated member rate reduced the first $5,466 hospital charge to $3,425, while the charge for the second procedure was lowered to $1,787 — $1,638 less.
Neither the bill nor the EOB explained why there was a second procedure listed, at a reduced price.
After examining Contos’ bill, Littenberg said it’s standard for providers to bill for two colonoscopies if they remove two or more polyps in different ways, because of the extra work. As in this case, hospitals typically use a modifier code that reduces the amount charged for the second billed colonoscopy so they charge only for the extra work, he added.
“How do you explain that in sensible terms that anyone could understand?” Littenberg said.
Even with that reduction, Littenberg said, he thought Contos’ total out-of-pocket cost of $4,047 was “a lot, though not rare for large academic centers.”
Contos’ insurance documents show Aetna’s negotiated rate for his colonoscopy at Northwestern was more than twice the insurer’s median negotiated rate for the same procedure at other Chicago-area hospitals, according to Forrest Xiao, director of quantitative research at Turquoise Health, a company that gathers health care price data.
In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged for two colonoscopies. A Northwestern representative said that because of the modifier code, he wasn’t actually being billed for two procedures, which Contos found bewildering.
“I told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,'” he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.
The resolution
In an email, Contos told the billing department that its charge was “ridiculously high.” A representative responded that Northwestern’s pricing is in line with other academic medical centers in Chicago and “non-negotiable” — and that his account would be turned over to a collections agency.
CVS Health spokesperson Phillip Blando said in a written statement to KFF Health News that the claims for Contos were “paid accurately” by Aetna, declining further comment. (CVS Health owns Aetna.)
Northwestern did not respond to multiple requests for comment.
Contos said he wrote to his physician that he was regretfully dropping him and leaving Northwestern entirely because of the health system’s high pricing.
He said he’s still experiencing periodic symptoms, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.
The takeaway
To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.
Bill of the Month
To get a sense of how much a diagnostic colonoscopy could cost, patients can consult a hospital’s price website and an insurer’s cost-estimator website, both required by federal price transparency rules.
Patients also can look up a good-faith estimate of the cash price, which can be lower than the price for patients using insurance to pay for a procedure. In addition, they can check prices through websites such as Turquoise Health and Fair Health, which draw from federal price transparency data or claims data from insurers.
Still, the actual cost could be higher than the estimate if the colonoscopy finds one or more polyps that need to be removed and biopsied, which occurs in at least 40% of all colonoscopies, Littenberg said. Patients should ask whether the price includes those potentially extra services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat lesions that could cause problems — regardless of the number found.
It all should be easier for patients, Xiao said: “You shouldn’t have to be a medical billing expert to know what you’re going to pay.”
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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This article first appeared on KFF Health News and is republished here under a Creative Commons license.
Leaving Israel is easier, Shira Z. Carmel thinks, by saying it’s just for now. But she knows better.
For the Israeli-born singer and an increasing number of relatively well-off Israelis, the Oct. 7, 2023 Hamas attack shattered any sense of safety and along with it, Israel’s founding promise: to be the world’s safe haven for Jews. That day, thousands of Hamas militants blew past the country’s border defenses, killed 1,200 Israelis and dragged 250 more into Gaza in a siege that caught the Israeli army by surprise and stunned a nation that prides itself on its military prowess. This time, during what became known as Israel’s 9/11, the army didn’t come for hours.
Ten days later, a pregnant Carmel, her husband and their toddler boarded a flight to Australia, which was looking for people in her husband’s profession. And they spun the explanation to friends and family as something other than permanent – “relocation” is the easier-to-swallow term – acutely aware of the familial strain and the shame that have shadowed Israelis who leave for good.
“We told them we’re going to get out of the line of fire for awhile,” Carmel said more than a year later from her family’s new home in Melbourne. “It wasn’t a hard decision. But it was very hard to talk to them about it. It was even hard to admit it to ourselves.”
Thousands of Israelis have left the country since Oct. 7, 2023, according to government statistics and immigration tallies released by destination countries such as Canada and Germany. There’s concern about whether it will drive a “brain drain” in sectors like medicine and tech. Migration experts say it’s possible people leaving Israel will surpass the number of immigrants to Israel in 2024, according to Sergio DellaPergola, a statistician and professor emeritus of Hebrew University in Jerusalem.
Thousands of Israelis have opted to pay the financial, emotional and social costs of moving out since the Oct. 7 attack, according to government statistics and families who spoke to The Associated Press in recent months after emigrating to Canada, Spain and Australia.
Israel’s population continues to grow toward 10 million people. But it’s possible that 2024 ends with more Israelis leaving the country than coming in. That’s even as Israel and Hezbollah reached a fragile ceasefire along the border with Lebanon and Israel and Hamas inch toward a pause in Gaza.
Israel’s Central Bureau of Statistics estimated in September that 40,600 Israelis departed long-term over the first seven months of 2024, a 59% increase over the same period a year earlier, when 25,500 people left. Monthly, 2,200 more people departed this year than in 2023, the bureau reported.
The Israeli Ministry of Immigration and Absorption, which does not deal with people leaving, said more than 33,000 people have moved to Israel since the start of the war, about on par with previous years. The interior minister refused to comment for this story, a spokesperson said.
Other clues, too, point to a notable departure of Israelis since the Oct. 7 attacks. Gil Fire, deputy director of Tel Aviv Sourasky Medical Center, said some of its star specialists with fellowship postings of a few years in other countries began to waver about returning.
“Before the war, they always came back and it was not really considered an option to stay. And during the war, we started to see a change,” he said. “They said to us, ‘We will stay another year, maybe two years, maybe more.'”
Fire says it’s “an issue of concern” enough for him to plan in-person visits with these doctors to try to draw them back to Israel.
Michal Harel, who moved with her husband to Toronto in 2019, said that almost immediately after the attacks, the phone began ringing – with other Israelis seeking advice about moving to Canada. On Nov. 23, 2023, the couple set up a website to help Israelis navigate moving, which can cost at least 100,000 Israeli shekels, or about $28,000, Harel and other Israeli relocation experts said.
Not everyone in Israel can just pack up and move overseas. Many of those who have made the move have foreign passports, jobs at multinational corporations or can work remotely. People in Gaza, where local health officials say more than 45,000 people have been killed, have even less choice. Harel reported that the site has received views from 100,000 unique visitors and 5,000 direct contacts in 2024 alone.
Aliya – the Hebrew term for used for immigration, literally the “ascent” of Jews into Israel – has always been part of the country’s plan. But “yerida” – the term used for leaving the country, literally the “descent” of Jews from Israel to the diaspora, emphatically has not.
A sacred trust and a social contract took root in Israeli society. The terms go – or went – like this: Israeli citizens would serve in the military and pay high taxes. In exchange, the army would keep them safe. Meanwhile, it’s every Jew’s obligation to stay, work and fight for Israel’s survival.
“Emigration was a threat, especially in the early years (when) there were problems of nation-building,” said Ori Yehudai, a professor of Israel studies at Ohio State University and the author of “Leaving Zion,” a history of Israeli emigration. “People still feel they have to justify their decision to move.”
Shira Carmel says she has no doubt about her decision. She’d long objected to Netanyahu’s government’s efforts to overhaul the legal system, and was one of the first women to don the blood-red “Handmaid’s Tale” robes that became a fixture of the the anti-government protests of 2023. She was terrified as a new mom, and a pregnant one, during the Hamas attack. This was not the life she wanted.
Meanwhile, Australia beckoned. Carmel’s brother had lived there for two decades. The couple had the equivalent of a green card due to Carmel’s husband’s profession. Basic logic, she says, pointed toward moving. They were able to catch a free flight out on seven hours’ notice.
And yet, Carmel recalls the frenzied hours before the flight out in which she said to her husband in the privacy of their bedroom: “My God, are we really doing this?”
They decided not to decide. They packed lightly. But weeks in Australia became months, and the couple decided to have the baby there. They told their families back in Israel that they were staying “for now.”
“We don’t define it as ‘forever,'” Carmel said on Tuesday. “But we are for sure staying for the foreseeable future.”
Although 2024 is winding down, the U.S. housing crisis lives on. But even as steep home prices and elevated mortgage rates sideline many would-be homebuyers, some real estate markets around the country continue to attract buyers.
The National Association of Realtors (NAR) this month released a list of 10 local housing markets it expects to be hot spots in 2025, outperforming the rest of the country in sales. The locations have been chosen by NAR based on their current individual strengths across 10 key economic, demographic and housing factors that are considered predictors of future market activity.
“Important factors common among the top-performing markets in 2025 include available inventory at affordable price points, a better chance of unlocking low mortgage rates, higher income growth for young adults and net migration into specific metro areas,” said Lawrence Yun, NAR chief economist and senior vice president of research, in the report.
One of those factors is the share of “locked-in” homeowners in a given area — those with low mortgage rates from previous years who are in no rush to sell and take on new loans at much higher rates. Areas with fewer locked-in homeowners were considered by NAR to be hotter than others as they are more likely to see properties listed. More listings means and more opportunities for buyers.
Predictions for 2025
NAR expects mortgage rates to stabilize, if not fall as sharply as some house-hunters were hoping, next year. The Federal Reserve on Wednesday announced its third straight cut in its benchmark rate, lowering the federal funds rate by another quarter of a percentage point. Although mortgage rates don’t always mirror the Fed’s rate moves, they tend to track the yield on the 10-year Treasury note, rising or falling along with the return on government debt.
NAR thinks the Fed will continue to cut borrowing costs in 2025 and predicts that mortgage rates will settle around 6%, bringing in millions more buyers back to the market. The Fed is now hinting at only two rate cuts in 2025, down from its previous projection in September of four. Experts expect mortgage rates may come down slightly with the Fed’s the latest reduction possibly contributing to a modest decline.
The real estate group also expects home prices to rise further in the coming year, though more slowly than in 2024. The number of homes on the market is and will continue to increase in 2025.
“Homebuyers will have more success next year,” Yun said in the report. “The worst of the affordability challenges are over as more inventory, stable mortgage rates and continued job and income growth pave the way for more Americans to achieve homeownership.”
Here, in alphabetical order, are NAR’s 10 top housing hot spots for 2025.
Boston-Cambridge-Newton, Massachusetts-New Hampshire
David L Ryan/The Boston Globe via Getty Images
Buying a home in Boston-Cambridge-Newton area isn’t exactly cheap, with home prices averaging $694,494, according to Zillow. That’s more than $200,000 north of the national average home price of $430,584.
Still, the metro area has a number of strengths. For one, NAR expects the local housing market, which includes portions of southern New Hampshire, next year to benefit from stabilizing mortgage rates, which would likely mean fewer locked-in homeowners. Mortgage rates in Boston typically skew lower than the national average, according to the real estate group, which noted that Boston also has a good number starter-homes. Typically priced at 85% of the median-priced home, starter homes are critical for first-time buyers.
Charlotte-Concord-Gastonia, North Carolina-South Carolina
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In addition to 10% job growth over the last five years, Charlotte has a significant share of affordable housing, with 43% of homes priced below $324,000 — a huge draw for first-time buyers and young families. The average interest rate in the area is 6.85%, slightly below the national average of 6.89% for a 30-year fixed mortgage.
Grand Rapids-Kentwood, Michigan
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Grand Rapids, Michigan, offers an ample stock of affordable homes, with the average home price at $271,96, while mortgage rates hover around 6.9%, slightly above the national average. But because Grand Rapids has a small proportion of mortgage originations with rates below 6%, NAR predicts fewer lock-ins and more listings in 2025.
Greenville-Anderson, South Carolina
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With home prices averaging $307,315 and a large influx of new residents, houses in Greenville don’t stay listed for long — typically about 17 days. Mortgage rates run just above the national average, at 6.9%, most likely because of recent foreclosures happening in the state, according to MorgageRates.com.
NAR points to the 42% of homes categorized as starter homes in Greenville as another reason why it predicts the local housing market will be a standout for families and young professionals in 2025.
Hartford-East-Hartford-Middletown, Connecticut
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When it comes to affordability, Hartford’s average home price of $178,696 is hard to beat. In 2023, The city’s average mortgage rate of 6.5% was one of the lowest among the top markets. Connecticut’s capital city also has the highest proportion of homeowners surpassing the area’s average tenure of 17 years, an indication of a potential increase in local inventory, according to NAR.
Indianapolis-Carmel-Anderson, Indiana
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Indianapolis made NAR’s list because of strong job growth and housing affordability. Nearly 42% of the housing stock is priced below $236,000, with the average home value at $223,261. “With fewer ‘locked-in’ homeowners than the national level, this area is likely to see more available inventory as mortgage rates stabilize around 6% next year,” according to NAR.
Kansas City, Missouri-Kansas
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Kansas City’s generally lower average mortgage rate and smaller share of locked-in homeowners makes it a favorable market for financing and inventory. The average house is priced at $233,826, making homeownership in the area affordable for one in three millennials. Affordability plus competitive financing will make the Kansas City housing market a top performer in 2025, according to NAR.
Knoxville, Tennessee
Marcia Straub/Getty Images
One of the hottest housing markets in Tennessee, Knoxville is a place where newcomers go to settle down — roughly 50% of movers to the area decide to buy a home, NAR says. The average value of a home in Knoxville is $350,614, making this city located in the foothills of the Great Smoky Mountains affordable compared with other major cities.
Phoenix-Mesa-Chandler, Arizona
Gregory Clifford/Getty Images
The average home value in Phoenix is $414,977. The relatively affordable housing stock, plus a comparatively lower cost of living and strong job growth, have made Arizona’s capital city a key destination for Californians looking to relocate. “Demographic shifts and economic expansion has established Phoenix as a prosperous and dynamic market,” according to NAR.
San Antonio-New Braunfels, Texas
Paul Giamou Photography Ltd./Getty Images
The average home in San Antonio is priced at $250,834, which makes it one of the few markets to see a decrease in residential real estate costs over the past year. The city, home of The Alamo, also has had one of the strongest records of job growth in the U.S. in recent years, according to the NAR report, and it continues to attract a steady influx of new residents.
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Planned Starbucks strikes in 3 cities could spread nationwide during crucial holiday shopping season
Workers at Starbucks stores plan to go on a five-day strike starting Friday to protest lack of progress in contract negotiations with the company.
The strikes, which would come a day after online retail giant Amazon was also hit by a walkout in the crucial final shopping days the season, are scheduled to begin in Los Angeles, Chicago and Seattle and could spread to hundreds of stores across the country by Christmas Eve.
Starbucks Workers United, the union that has organized workers at 535 company-owned U.S. stores since 2021, said Starbucks has failed to honor a commitment made in February to reach a labor agreement this year. The union also wants the company to resolve outstanding legal issues, including hundreds of unfair labor practice charges that workers have filed with the National Labor Relations Board.
The union noted that Starbucks’ new Chairman and CEO Brian Niccol, who started in September, could make more than $100 million in his first year on the job. But the company recently proposed an economic package with no new wage increases for unionized baristas now and a 1.5% increase in future years, the union said.
“Union baristas know their value, and they’re not going to accept a proposal that doesn’t treat them as true partners,” said Lynne Fox, president of Workers United.
Seattle-based Starbucks said Workers United prematurely ended a bargaining session this week. Starbucks has nearly 10,000 company-owned stores in the U.S.
“We are ready to continue negotiations to reach agreements. We need the union to return to the table,” Starbucks said in a statement.
Starbucks said it already offers pay and benefits – including free college tuition and paid family leave – worth $30 per hour for baristas who work at least 20 hours per week.
The strikes aren’t the first during Starbucks’ busy holiday season. In November 2023, thousands of workers at more than 200 stores walked out on Red Cup Day, a day when the company usually gives away thousands of reusable cups. Hundreds of workers also went on strike in June 2023 to protest after the union said Starbucks banned Pride displays at some stores.
The union and company struck a different tone early this year when they returned to the bargaining table and pledged to reach an agreement. Starbucks said it has held nine bargaining sessions with the union since April and has reached more than 30 agreements with the union. But the two sides now appear to be at an impasse.
“In a year when Starbucks invested so many millions in top executive talent, it has failed to present the baristas who make its company run with a viable economic proposal,” said Fatemeh Alhadjaboodi, a Starbucks barista from Texas and bargaining delegate, in a statement.
Thousands of Jews have left leave Israel since the October 7 attacks
Looking for a home in 2025? Check out these 10 housing hotspots.
Planned Starbucks strikes in 3 cities could spread nationwide during crucial holiday shopping season
Thousands of Jews have left leave Israel since the October 7 attacks
Looking for a home in 2025? Check out these 10 housing hotspots.