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In case you haven’t heard, our health care system is messed up.

Exhibit 242813 is this new research out of Johns Hopkins, which looks at how some hospitals engage in blatant price gouging in order to maximize profits. The study’s authors looked at how much hospitals charged for a procedure, compared how much it actually cost them to provide it. While certain procedures, like routine inpatient care, had a charge-to-cost ratio that was close to even, other procedures were massively skewed. In some cases, the researchers found, hospitals were charging 28.5 times the cost of a procedure.

Analyzing the specifics of the mark-ups led the researchers to conclude that such price manipulations are more common among for-profit hospitals than their non-profit or government-run peers; and that complex procedures were more likely to have higher charge-to-cost ratios than more routine care.

Even if insurance providers are generally the ones bearing the brunt of this price gouging, it’s still a big problem in the industry. “[Steep markups] affect uninsured and out-of-network patients, auto insurers and casualty and workers’ compensation insurers,” study co-author Gerard F. Anderson, of the university’s Bloomberg School of Public Health, said. “The high charges have led to personal bankruptcy, avoidance of needed medical services, and much higher insurance premiums.”