Your health-care costs.

Despite money-saving changes, hidden expenses affect consumers and hospitals.

A hospital bill is often a big enough shock to put us right back in the hospital.

In 1980 the average hospital bill was $2,166, according to the American Hospital Association. By 1989 the charge for an average hospital stay had nearly tripled to $6,485.

But before you complain too bitterly, consider the costs hospitals confront. "The overhead would astound most patients," says William Erwin, spokesman for the AHA.

"Less than 2 percent of the average hospital bill actually goes to profits," adds Richard Clarke, president of the Healthcare Financial Management Association, a national professional organization for industry financial managers.

"Hospitals aren't trying to drain patients dry," he says. "On the contrary, they're struggling to preserve high-quality care and to keep their doors open so that treatment remains readily available."

In short, hospitals - large and small - are increasingly boxed in by their overhead and must reluctantly pass on their costs to patients.

No doubt your next hospital bill will reflect these formidable operating costs, which is why you have the right to know precisely what they include.

Among a hospital's major - and largely hidden - costs of doing business are these:

BAD DEBT.

"Twenty cents of every dollar that you are charged pays the bill of someone who either couldn't or for some reason didn't pay," says Erwin of the AHA.

The vast majority of those who do not pay are uninsured, a group whose ranks are swelling daily. Today, some 36 million Americans - 1 out of 7 - do not have health-care coverage. Tens of millions more have severely restricted, inadequate protection.

In 1989 alone, America's hospitals absorbed $13.2 billion worth of unpaid bills.

SHRINKING GOVERNMENT SUPPORT.

To operate, hospitals depend heavily on Medicare and Medicaid insurance reimbursements. But since the early 1980s, hospitals have been reimbursed at a fixed rate that for the past several years has frequently fallen short of actual costs.

Medicare is the federal health insurance program for the elderly and disabled; Medicaid provides insurance for the nation's poorest families.

"Two thirds of all hospitals lose money caring for Medicare patients. And nine out of 10 lose money on Medicaid patients," Erwin says.

SOARING WAGES.

In 1990 hospital workers received an average raise of 8.2 percent - more than double the national average, the AHA reports. What's more, industry analysts predict that hospital wages will continue to climb throughout the nineties.

"Key hospital professionals are in high demand and short supply. To attract skilled employees, hospitals simply must increase wages and benefits," Erwin explains.

PATIENT DEMAND FOR THE BEST

TREATMENT POSSIBLE.

"As Americans we expect - and demand - the absolutely best care available," says Carolyne Davis, R.N., Ph.D., a leading health-care consultant and former head of the U.S. Health Care Financing Administration.

That care doesn't come cheaply. A case in point: the magnetic resonance imaging scanner, an imaging tool with enormous medical value. Physicians nationwide routinely use MRI to peer into the body and diagnose brain tumors and other disorders without invasive surgery. Its price tag, however, is a daunting $1.2 million to $2.5 million.

MRI, of course, is not the only piece of high-tech equipment relentlessly driving up hospital costs. Any number of medical innovations - machines used in lithotripsy to disintegrate kidney stones, mammogram units and other scanning machines, for example - also increase the price of care.

And don't forget this: "Highly specialized workers need to be hired and trained to use [hightech] equipment," says Charles S. Lauer, publisher of Modern Healthcare, the hospital industry's leading trade magazine. "And like anything else we own, that equipment doesn't last forever. There's always a new model or a new upgrade, and that, of course, means more money."

MOUNTING PAPERWORK.

"To be paid, hospitals must deal with an unbelievable array of government and private insurers, each with its own set of detailed rules," says Healthcare Financial Management Association president Clarke. This drain on personnel trickles down into your bill.

MORE SERIOUSLY ILL PATIENTS.

"The average hospitalized patient is significantly more ill than in the past," Erwin reports. A major reason for this trend is the steady rise in the number of older patients admitted to America's hospitals. "Treatment of the elderly is typically more involved and requires longer stays," Erwin says. In 1990 the elderly accounted for 46 percent of all hospital inpatient days.

Combine each of these hidden costs and you have the reason that hospital bills are frustratingly high to patients and hospitals alike - despite hospital efforts to reduce costs such as more efficient use of personnel and joint purchasing with other institutions. But the good news is that the "overall quality of care in American hospitals is still the best in the world," Dr. Davis says.