After Gebel moved her treatment from Seattle to Alaska, where she lived, she found it was priced much higher in her home state. (Ash Adams/KFF Health News).

Editor's note: This story is from NPR's KFF Health News column Bill of the Month, which investigates high healthcare costs.

Emily Gebel was trying to figure out why she was having difficulty breastfeeding. That's when she felt a lump.

Gebel, a mom of two kids, went to her medical care physician in Juneau, Alaska, who referred her for screening, she stated.

Her 9-month-old was asleep in her arms when she got the outcomes.

" I got the call from my primary care nurse informing me it was cancer. And I remember I simply sat there for probably at least another half an hour approximately and sobbed," Gebel stated.

Juneau, the state capital, has about 31,700 citizens, who are served by the city-owned Bartlett Regional Hospital. However Gebel said she has numerous pals who have likewise had cancer, all of whom suggested she seek treatment out of town because they felt bigger cities would have much better care.

She opted for treatment in Seattle, the closest significant American city to Alaska. She went through surgical treatment at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she stated she picked since it offers a lower-dose chemotherapy.

During chemo, she learned she had phase 4 breast cancer, she stated.

Commuting to Seattle for chemo each week-- nonstop flights last as long as 2 hours and 45 minutes-- ended up being strenuous. Gebel began treatment at Bartlett Regional Hospital after her Seattle physician taught health center staffers there how to administer her chemo program.

Then the bill came.

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The client: Emily Gebel, 37, guaranteed through her husband's employer by Premera Blue Cross. She was formerly covered by Moda Health.

Medical service: One round of metronomic chemotherapy, which involves routine infusions at lower however more frequent doses and over a longer period than conventional chemotherapy.

Provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The healthcare facility is a tax-exempt facility owned by the city and district of Juneau, though most of its earnings comes from the services it supplies, according to medical facility authorities. Lifespring is a stand-alone, doctor-owned cancer center in Seattle.

Total bill: The prices for Emily's chemo infusions at Bartlett Regional Hospital differed week to week. A healthcare facility bill revealed one infusion in July was noted at $5,077.28-- more than three times the price for a comparable mix of drugs at the Seattle clinic, $1,611.24.

What offers: In the United States, the rate for the same medical service can vary based upon where it is received. And for those living in remote areas like Alaska, the rate difference can put care even more out of reach.

Emily's direct experience with this disparity began after her spouse, Jered, asked for a cost price quote from Bartlett Regional Hospital. It said Emily's chemo would cost around $7,500 per weekly infusion, more than 4 1/2 times what she had actually been charged in Seattle.

" The e-mail came through with the expense quote, and it's like, ‘‘ Oh my goodness, this needs to be wrong," Jered said.

Jered said Emily had met her annual out-of-pocket optimum, indicating her insurance would cover the expenses of her treatment, however from the start, the disparity just troubled him.

When Emily received an expense for a couple of rounds of her weekly chemo treatments, it revealed that the health center charged more than triple what the Seattle clinic provided for a round of chemo, asking higher prices for every related service and medication she got that week.

The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle center. Among Emily's drugs cost $714, more than 3 times the price at the clinic.

It was even the tiniest things: The medical facility charged $19.15 for Benadryl, about 22 times the center's price of 87 cents.

Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not respond to requests for remark.

Sam Muse, the medical facility's former primary monetary officer who no longer works there, said Bartlett Regional Hospital officials figured out rates by taking a look at average wholesale prices and what other facilities in the area charge. Muse said the health center had to represent high operating expense.

" Anything that we charge certainly needs to take into account … … the cost of just providing healthcare in a rural setting like Juneau," Muse said. "We're not available by road at all, just ferryboat or plane.".

Juneau's separated geography makes reaching lots of resources a difficulty. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged in between Canada, the Pacific Ocean, and Glacier Bay National Park & & Preserve. Neither Anchorage nor Vancouver, its closest major cities, is nearby.

The health center-- the only one in the city and biggest in the panhandle-- deals with a little number of cancer patients, a minimum of a couple of hundred in 2015, Muse stated. Its 2 oncologists live outside the city and fly into Juneau 6 times a month, stated Erin Hardin, a health center spokesperson.

Bartlett invested nearly $11 million last year to fly and pay in nurses, doctors, and other staffers who live outside the city, Muse stated.

We're "looking for that middle ground in between keeping care here and keeping costs down and how do we do that in a sustainable way for the long term," Muse stated.

Despite the fact that research study shows Alaskans look for emergency situation care and are admitted to the health center less typically than many Americans, they had the third-highest health care expenses per capita in 2020.

" Alaska is special in that it's little, it's remote, for that reason it's more pricey," said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied healthcare expenses in Alaska when he taught there.

Guettabi said health centers typically require to use higher incomes to recruit physicians and nurses ready to reside in Alaska, which has a higher cost of living than many states.

Towns or entire areas may have couple of experts and just one healthcare facility, developing a lack of competition that might increase costs, Guettabi said. It's likewise more costly to deliver items there, consisting of medical supplies.

Alaska's expenses are higher even when taking all those aspects into account, Guettabi stated. In Anchorage, for instance, costs for medical items increased almost three times much faster from 1991 through 2017 than costs in general.

Alaska also has an unique policy that may be increasing costs. Its "80th percentile rule" was enacted in 2004 to restrict the quantity of cash clients pay when treated by companies outside their health insurance providers' network. However like numerous experiments meant to control costs, the guideline has instead been increasing health care spending, according to a study by Guettabi.

" Critics think the rule might be contributing to that skyrocketing costs, partially since gradually suppliers could increase their charges-- and insurance coverage payments would need to keep up," the research study noted.

The resolution: Emily got an expense from the medical facility in September, more than five months after beginning treatment there.

It stated Emily owed about $3,100 even though a previous explanation of advantages said she 'd met her out-of-pocket limitation.

Jered stated he called healthcare facility billing authorities, who discovered that a medicine had been incorrectly coded and informed Jered that Emily's charge was zero.

" We know how difficult it is to pay these absurd medical bills," Jered said. "If I'm able to push back a little bit against this enormous system, well, hey, maybe other people can, too. And who understands, perhaps ultimately health care rates can come down.".

Emily said she's glad Jered knows how to deal with the monetary aspects of her care. Like numerous Americans, she might have just paid or ignored the incorrect costs, running the risk of being sent out to collections.

" I can't think of the amount of time I would need to spend on it while managing parenting and likewise handling finishing treatment, going through the sickness that accompanies that, and simply generally feeling extremely run down," she stated.

The takeaway: Alaska government professionals, nonprofits, and authorities have suggested techniques to decrease the expense of health care. The state is thinking about rescinding the 80th percentile rule and carrying out value-based care, which stresses paying service providers based upon health results.

What should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out rates at a health care system in a state next door.

In any case, prepare yourself to promote for yourself.

Jered found out about medical billing by following the Bill of the Month series and reading "Never Pay the First Bill," a book by Marshall Allen, a former ProPublica press reporter.

Demand detailed expenses and ensure the codes match the services you got, Jered stated. Keep in mind any costs that appear outrageous. Set up an in-person meeting with an official in the supplier's finance department if you have concerns. A phone call is better than email if that's not possible. Make certain to record all discussions, so you have a record.

Come prepared with your files and evidence, consisting of the rate paid by Medicare, the federal insurance system for those 65 and older. And remember that the individual you're speaking with isn't to blame for your health care costs.

" Don't come at them upset, don't come at them as viewing them as the enemy-- due to the fact that they're not," Jered stated. "They are working within the very same broken system.".

Emmarie Huetteman of KFF Health News modified the digital story, and Taunya English of KFF Health News edited the audio story. NPR's Will Stone modified the audio and digital story.

KFF Health News, formerly known as Kaiser Health News (KHN), is a nationwide newsroom that produces in-depth journalism about health issues and is among the core operating programs at KFF-- the independent source for health policy polling, journalism, and research.

Copyright 2023 KFF Health News. To see more, visit KFF Health News.

Arielle Zionts, NPR.