With 46 million uninsured Americans and major health care reform possibly ahead, the roughly 5,000 CEOs at U.S. community hospitals aren t in an enviable position. In the 1980s, almost all hospital heads held advanced degrees in health administration, but the American College of Healthcare Executives says more than one in four of its member CEOs now has an MBA, which president Tom Dolan thinks has advantages and disadvantages. One plus: Business savvy sure helps in the $1 trillion U.S. hospital industry.

But along with that have come less welcome changes, like Wall Street style salaries and perks. Gary Mecklenburg, former CEO of Chicago s Northwestern Memorial Hospital, was paid $16.4 million from September 2005 to October 2006, including a nearly $11 million retirement bonus. A Northwestern spokesperson says the hospital complies with IRS standards of fair and reasonable compensation. Cathy Glasson, a nurses union leader in Iowa, says only recently have hospitals internally begun calling patients consumers or clients. Even that small shift hints at today s business model, she says. Focus less on care and more on profits.

These days, even nonprofit hospitals have become more entrepreneurial. Executives have all but replaced the nuns who once ran Catholic hospitals, and at least a few facilities have upped prices to several times what procedures cost. What s more, even though nonprofit hospitals get roughly $12.6 billion in annual tax breaks and billions more in government subsidies in exchange for community service, there s no standard for how much free care they must provide. Studies show many hospitals don t give enough free care to equal their tax breaks, and figures they report can be misleading. For instance, many facilities claim the amount they bill for a service instead of what it costs to provide it.

The Service Employees International Union recently criticized Beth Israel Deaconess Medical Center in Boston for reporting bad debt (unpaid bills for which it had already been partially compensated by the state) as charity care, inflating its free-care figure by about 20 percent. A Beth Israel spokesperson says hospital auditors have never found any cause for concern. And no wonder: The hospital was acting in accordance with IRS regulations.

After media coverage about how they often accept lower payments from insurers while charging higher list prices to the uninsured, hospitals are now more open to bargaining. So how can you take advantage? For starters, many facilities have financial counselors who can set up no-interest payment plans or adjust prices based on financial need all you have to do is ask. Or team up with an outfit such as North American Surgery which pairs patients willing to pay up front with small hospitals willing to give discounts and you could save up to 80 percent on common procedures like bypass surgery.

Kelly Proffitt, a 39-year-old teacher in Bassett, Va., knows the benefits of bargaining. In May, when her mother got a $12,000 bill from a hospital after spending almost a week there with a near-fatal blood infection, Proffitt hired a health-care advocate a private individual, often with insurance experience, who helps tackle charges. Weeks later, the hospital offered to cut the bill by 80 percent. The advocate found strings to pull we didn t even know existed, Proffitt says. To follow her example, visit www.billadvocates.com to find your own bill bargainer.

The hospital industry is in the midst of a building boom, having spent more than $100 billion on construction from 2002 through 2007, double the amount from the previous five years. Hospital executives argue that they re trying to make patients more comfortable, but critics claim much of the work is unnecessary, like putting waterfalls in the lobby, says Maggie Mahar, author of Money-Driven Medicine. And that cost trickles right back down to consumers.

What s more, when construction increases the number of hospital beds, doctors tend to fill them and charge accordingly. Researchers at Dartmouth University have repeatedly found that patients with chronic conditions spend more time in the hospital in areas with more hospital beds per capita. And during the last months of life, patients in bed-glutted regions like Miami spend 20 days in the hospital on average, compared with six days elsewhere.

The upshot for patients? Researchers have never found all that extra care is producing better health outcomes, says Paul Ginsberg, president of the Center for Studying Health System Change. In some cases, outcomes are actually somewhat worse.

Tensions are up between hospital executives and doctors, especially since many physicians have begun opening small outpatient-surgery centers or mini hospitals in direct competition with big hospitals. The CEOs worry such facilities which often focus on profitable specialties like liver transplants will shear off the most high-paying, wellinsured patients.

Orthopaedic surgeon William Reed has felt the blowback: In 2003, when he and 21 colleagues opened Heartland Spine & Specialty Hospital in Kansas City, Kan., he said the six biggest insurance firms in the area stopped talking to him about adding the facility to their networks. When Reed filed suit alleging tortious interference and civil conspiracy, his lawyers uncovered e- mail showing several large local hospitals had told the insurers they didn t want them working with Heartland. One hospital allegedly said it would drop an insurer that did. Five hospitals settled for undisclosed sums in spring 2008; the one that allegedly threatened to drop an insurer says its contracting uses a thorough, lawful approach. But says Reed, They were trying to find a way to choke me right out of business.

You can hardly log on to a hospital s website without a logo proclaiming it one of the country s best. Rankings have proliferated in recent years and are now offered by such varied sources as the for-profit firm HealthGrades and magazines like U.S. News & World Report. The problem is, consumers still don t know how to assess and research hospitals adequately, says Howard Peterson, managing partner of hospital-consulting firm TRG Healthcare, so image becomes everything. That s why each year when hospital rankings that factor in the reputation of a facility within the health care community get compiled, I can t even tell you how many e-mails I get wanting my vote, Peterson says.

How to find reliable rankings? For starters, look closely at what goes into these calculations. For example, a facility may label itself best hospital when only one division (say, ophthalmology) has won an award. Among rankers, HealthGrades (www.healthgrades.com) bases its ratings on more than 90 individual procedures and lets you access ratings based on mortality or complication rates of patients, as well as data on safety and what the hospital charges.

Hospital CEOs tend to focus on the mix of privately insured and Medicare patients at their hospitals, says Leah Binder, CEO of industry monitor The Leapfrog Group. And for good reason: Because Medicare reimbursements barely cover the cost of procedures, privately insured patients and their insurers often pay more to compensate. One study by PricewaterhouseCoopers predicted that by 2009, one of every four dollars spent by private insurers would cover such cost shifting. That can lead to some pretty outrageous charges. For example, says consumer advocate Nora Johnson, many hospitals bill about $30,000 for appendectomies when the cost to do the procedure is more like $4,200. (Insurers negotiate prices, usually somewhere between those two benchmarks.) But because it isn t easy to compare prices, Johnson says there are no checks and balances to keep hospitals from marking things up as much as they want.

Richard Clark, CEO of the Healthcare Financial Management Association, a professional group for hospital CFOs, says it s frustrating to hear arguments that pricing is arbitrary, since hospitals painstakingly adjust prices based on the number of patients covered by government programs and on market forces.

The hospital industry has been rapidly consolidating since the 1990s, with more than 100 merger-type deals announced or completed in 2007 alone. What does this mean for consumers? When a hospital buys another one close by, prices can jump more than 40 percent. That s because big chains have more leverage to demand higher rates from insurers, says Robert Town, professor of health policy at the University of Minnesota.

Hospitals say mergers ultimately help them improve quality they ll spend more on care and less on backoffice needs. But the process can cause customer-service snafus and occasionally compromise quality. Hospital consultant Corbett Price says it s very common for hospitals to have problems coordinating accounting systems after a merger, which can result in duplicate or flawed bills, for example. And since mergers gobble up competition, some critics say hospital CEOs no longer feel they have to address black marks like low nurse-to-patient ratios to compete.

Price urges concerned consumers to talk with their primary-care doctor about changes at a newly merged hospital and make sure the facility remains accredited by checking www.jointcommission.org. Another option: Wait at least three months for the dust to settle before going back to that hospital.

With more hospitals focused on financial survival, many are pushing the most profitable types of care. Nowhere is this trend more apparent than in advertising: A 2005 study of top academic medical centers ads found that 29 percent of those focused on specific treatments touted cosmetic procedures, while another 38 percent focused on experimental (read: high-priced) services like deep-brain stimulation for Parkinson s disease.

Critics worry hospitals are becoming dangerously out of sync with the needs of the public. Author Mahar says ERs are often crowded because hospitals don t want to expand this low-profit unit. Poor financials also explain why the U.S. doesn t have nearly enough burn units, she says, and why more than threequarters of hospitals don t offer palliative care. Clark says that while a focus on building up profitable parts of facilities is definitely going on, nonprofit hospitals also focus on making sure they are still providing the services the community needs while making a hospital financially sustainable.

Things have improved in recent years, but consumer advocates trying to make data publicly available on such topics as staph infection rates in hospitals often describe a multiphased process of resistance. First the executives just flat-out oppose you, says Denise Love, executive director of the National Association of Health Data Organizations. Then they say they love the idea but begin attacking the data points and methodology.

At HealthGrades, Chief Medical Officer Samantha Collier says she gets calls at least once a week from hospital CEOs or their underlings complaining about everything from her methodology to where they fall in the hierarchy of rankings. Granted, hospital execs have some legitimate concerns: For example, there s the issue of whether hospital researchers and raters are properly adjusting data to be easier on facilities seeing the toughest cases and thus posting higher mortality rates. But Mahar says hospitals stake in keeping the public underinformed is mostly business savvy. CEOs realize that patients walk away [from the hospital] knowing whether they like the food and the view, she says. They ve got no idea if they actually got good quality health care.