A 2,100% Markup: My Battle with a Vastly Overpriced Knee Brace — and U.S. Healthcare - MedCity News (2025)

Recently, I had a routine surgery to repair a torn meniscus in my right knee. This was a relatively simple procedure that many Americans need each year, the kind of thing that you would hope would come with no surprises. Instead, what I received was a firsthand look at ways that healthcare in the United States is often designed to drive up costs in pursuit of profit.

The day before my surgery, I was told that I would have to wear a specialized knee brace following my procedure. The brace would cost $3,300, a hefty price, though only 10% would come out of my own pocket. But as someone who has been in the healthcare space for over a decade, I’ve learned when to be skeptical about the costs of medical procedures and equipment.

So, out of curiosity, I researched the make and model of the brace that would be placed on my knee in the operating room. I learned it wasn’t a special brace at all. In fact, the same brace could be readily found on sites like Amazon for as little as $150.

Follow the money

The reason for this experience is as simple as it is disheartening: price gouging and intentional obfuscation have unfortunately become essential ingredients in an industry focused more on maximizing profits than on creating a sustainable and affordable health system.

To those of us with insurance coverage, some of this may be invisible – a reasonable $20 copay can obscure the potentially thousands of dollars that make up the total cost paid and provides no information on if that was a reasonable price to pay for that drug or service. Those true costs are hidden, and while insurance plays an important role in risk sharing, the current system too often incentivizes price inflation by insurers acting as a middleman.

There is another way. Third-party administrators (TPAs) make money administering health benefit plans on behalf of employers. They charge employers a straightforward monthly service fee, and they don’t monetize members visiting the doctor, filling a prescription, or going out of network. In other words, their business model incentivizes them to help people find and access the appropriate care for their needs, not to profit unnecessarily from it.

Health insurance companies offer administrative-only services as well, but often those services are neither visible nor easy to unravel for health plan members or the companies that contract with them.

For example, when someone receives care from a provider that is not within their health insurance company’s network, they are usually met with a higher billed rate. In that case, the health insurance company will offer to negotiate a lower rate and in return, the insurer typically keeps the majority of the difference between the initial amount that was billed by the doctor or facility and the final “allowed” amount they negotiated. It’s euphemistically called a “shared savings” arrangement.

But in reality, there should be no need to have to negotiate a different rate with a physician or facility based on whether it is contracted with an insurance network or not. Just like there should be no difference between the cost of a knee brace depending on whether I buy it on Amazon or get it from the surgeon or hospital.

Guidance for providers

Systemic change moves at a glacial pace. But providers, individual members, and benefits leaders can take steps to chip away at the oligopoly. And the first step is transparency.

For instance, if hospitals were required by law to publish wholesale and retail price lists, consumers would garner a better understanding of the actual acquired costs of drugs and services, compared to what’s being passed along to them or to enterprise customers. While hospitals are required to share standard changes, negotiated rates with insurance companies, and discounted cash prices, wholesale prices are still largely kept under wraps.

But efforts to curtail unexpected and unfair medical bills, like the No Surprises Act (NSA), have faced significant pushback. Widespread adoption of the NSA has been slow to roll out due to litigation from hospitals and insurance companies worried about their bottom lines.

In the interim, the price data that is being furnished is largely unhelpful. This so-called data consists of jumbled codes that even the most well-versed data scientists have struggled to untangle.

Guidance for members

As patients, much of the onus is unfortunately on us to dig into why we’re paying what we’re paying. The best thing we can do is develop staunch curiosity about every medical bill that comes our way.

If you’re going to be charged for a piece of equipment like a knee brace, do your research like I did. See if alternatives exist at a lower price online. Ask your healthcare providers if you can bring in your own equipment. If they say no, demand to know why. You deserve to know why.

Odds are, they’ll tell you it’s between you and your insurance company. It’s then incumbent on us to ask insurance providers what things will cost. If they aren’t willing to tell you, then it’s time to bring that information to your employer’s HR or benefits team.

Guidance for employers and benefits leaders

Once made aware of unfair pricing, benefits leaders should confront their insurance providers directly. Ask them how they make money from your health benefit plan. Be prepared to encounter that veil of complexity and vagueness again. But at least you’ll know you’ve done your due diligence.

My biggest recommendation for employers struggling to navigate the world of healthcare plans is to work with an independent entity that has no perverse incentive to inflate the price of care. Employers can look by system, geography, or provider to see what providers are charging, and they can analyze distribution to ascertain whether pricing is fair or within a reasonable set of boundaries.

At the benefit design level, employers can work with third parties to redirect members to providers that don’t behave egregiously. If enough people are redirected, then this will force centers to bring pricing in line.

We can fix US healthcare by asking basic questions

My story is not a unique one, but rather a reflection of how the health insurance oligopoly abuses the average American patient. When I shared this story with my peers, many seemed to have had a similar experience. We spend around twice as much on healthcare as other industrialized nations, and as of February 2024, Americans collectively owe at least $220 billion in medical debt.

This cannot continue. Pricing must be grounded in economic fact and a reasonable rate of margin, rather than an endless hunger for profit. The best weapon we have against unethical pricing practices is curiosity — our willingness to peel back the veil of obfuscation. The more people ask questions, the more they’ll create a groundswell of change.

And if we pull on the thread of that veil enough, it will unravel.

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