But then, why not? If healthcare has become a mercenary marketplace where the bottom line drives what care we get, why shouldn't consumers get into the act? You might be surprised how many doctors - and especially hospitals - are willing to negotiate a big bill into a smaller one.

"There's a lot of negotiation that can be done," says Dr. Vincent Riccardi, who runs a patient advocacy organization called American Medical Consumers. "It happens all the time."

Individual patients may not think they have much leverage with a big hospital or medical practice. But consider that both are businesses that regularly haggle with health plans over prices, and routinely give discounts of 10 percent to 30 percent and more to their large customers. There's no reason why you should pay the sticker price for a gallbladder removal if you don't have to.

Plenty of consumers could find themselves suddenly facing a staggering medical bill without help from insurance. To begin with, there are the 43 million Americans without health coverage at all. But even people with insurance can end up owing thousands for a major illness or operation. Think about it - a 20 percent copay for hospital care mounts up quickly. Even if you belong to an HMO, you might decide to seek out a specialist who isn't on the approved list of doctors, and pay the bill yourself.

Instead of meekly handing over what the bill says you owe, consider asking for the same kind of discount that the health plans get. It's mostly a matter of finding the right person to talk to. In a doctor's office, bypass the receptionist and go directly to an office manager.

"Doctors aren't in the business of haggling over bills, but they care about your health and are usually willing to work with you," says Kevin Flynn, who runs a Philadelphia-based patient advocacy service called Healthcare Advocates. "They want to help you."

Hospitals may seem like imposing bureaucracies, but most of them spend a lot of time and money tracking down patients who simply can't pay a huge bill and have budgeted ahead of time for "bad debt" that can't be collected. They'd rather negotiate a deal to get paid part of the total, or work out something in advance. Contact the business manager's office at the hospital. And don't give up at the first "no."

"You'll always run across, 'no, no, no,' but if you're persistent and talk to the right people they'll work with you," Flynn says.

Hospital bills are so confusing and often riddled with errors, that many hospital billing departments will give you an automatic 10 percent off if you simply agree not to have the bill audited, or checked for errors, Riccardi advises. That kind of thing is done with insurance companies all the time.

If you're planning an elective surgery, call around to area hospitals in advance and ask about per-diem rates, meaning what they charge to stay in the hospital each day. Let them know that you're aware that nobody but uninsured individuals pays full charges in a hospital, and ask for a discount.

A few hospitals have started offering creative financing options. For instance, Franklin Memorial Hospital in Farmington, Maine, allows patients to work off their debt in the hospital, answering phones, mopping floors or clipping hedges. "We've had over 200 hospitals from across the nation call to ask about our program, and many of them told me they've either implemented the program or are going to," says Franklin spokesman Pete Tucker. If you're facing an unmanageable bill, it's worth asking about.

If you're not comfortable doing the negotiations on your own, get some help from an advocate such as Riccardi or Flynn. Another option is finding a local case manager who is versed in both medicine and insurance (see Patients' Rights column on this topic). They'll know the medical billing lingo, and may even be able to locate benefits a patient doesn't know about (one that's commonly overlooked is veterans medical benefits).

Another option for finding discounted health care is to purchase one of the many new medical discount cards. Companies that offer them charge a monthly fee and promise discounts of anywhere from 20 to 60 percent on doctor's fees, eyeglasses, dental work and prescriptions.

This new business model isn't without controversy - insurance regulators in several states contend that they are actually offering a form of health insurance without bothering to get a license or set up consumer safeguards such as a pool of money to back up the plan. In fact, California and Washington have outlawed such plans within their borders.

But it's possible one of these plans could help you, if you're careful in choosing one whose discounts you can confirm by calling around to the medical services you might actually use in your community.

Flynn suggests another way to safeguard your pocketbook with a medical discount card. Have your doctor agree in writing that the card vendor is responsible for your bill, not you. That way, if the card operators fail to pay the doctor bill a year down the line, the bill collectors won't be coming after you.

That's the downside of the healthcare consumer revolution - the increasing burden on individuals to look out for themselves in a dog-eat-dog marketplace. At the same time, this new role gives consumers a chance to use their newfound clout when it comes time to pay the bill.

"More and more, healthcare is becoming a marketplace run by consumers," says advocate Flynn. "Hospitals and insurance companies and doctors are all realizing this and are trying to meet their customers' demands."