American hospital bills are
littered with multiplying fees, many of which don’t even exist in other
countries
JULY 9, 2018 12:00AM (UTC)
On the first morning of Jang
Yeo Im’s vacation to San Francisco in 2016, her 8-month-old son, Park Jeong
Whan, fell off the bed in the family’s hotel room and hit his head.
There was no blood, but the
baby was inconsolable. Jang and her husband worried he might have an injury
they couldn’t see, so they called 911, and an ambulance took the family —
tourists from South Korea — to Zuckerberg San Francisco General Hospital
(SFGH).
The doctors at the hospital
quickly determined that baby Jeong Whan was fine — just a little bruising on
his nose and forehead. He took a short nap in his mother’s arms, drank some
infant formula and was discharged a few hours later with a clean bill of
health. The family continued their vacation, and the incident was quickly
forgotten.
Two years later, the bill
finally arrived at their home: They owed the hospital $18,836 for a visit
lasting three hours and 22 minutes, the bulk of which was for a mysterious fee
for $15,666 labeled “trauma activation,” also known as “a trauma response fee.”
“It’s a huge amount of money
for my family,” said Jang, whose family had travel insurance that would cover
only $5,000. “If my baby got special treatment, OK. That would be OK. But he
didn’t. So why should I have to pay the bill? They did nothing for my son.”
American hospital bills are
today littered with multiplying fees, many of which don’t even exist in other
countries: fees for blood draws, fees for checking the blood oxygen level with
a skin probe, fees for putting on a cast, minute-by-minute fees for lying in
the recovery room.
But perhaps the pinnacle is
the “trauma fee,” in part because it often runs more than $10,000 and in part
because it seems to be applied so arbitrarily.
A trauma fee is the price a
trauma center charges when it activates and assembles a team of medical
professionals that can meet a patient with potentially serious injuries in the
ER. It is billed on top of the hospital’s emergency room physician charge and
procedures, equipment and facility fees.
Charges ranged from $1,112 at
a hospital in Missouri to $50,659 at a hospital in California, according to Medliminal,
a company that helps insurers and employers around the country identify medical
billing errors.
“It’s like the Wild West. Any
trauma center can decide what their activation fee is,” says Dr. Renee Hsia,
director of health policy studies in the emergency medicine department at the
University of California-San Francisco.
Hsia is also an emergency
medicine doctor at Zuckerberg San Francisco General Hospital, but was not
involved in the care of the patients discussed in the story — and spoke about
the fees generally.
Comprehensive data from the
Health Care Cost Institute shows that the average price that health insurers
paid hospitals for trauma response (which is often lower than what the hospital
charges) was $3,968 in 2016. But hospitals in the lowest 10 percent of prices
received an average of $725 — while hospitals in the most expensive 10 percent
were paid $13,525.
Data from Amino, a health cost
transparency company, shows the same trend. On average, Medicare pays just
$957.50 for the fee.
According to Medicare
guidelines, the fee can be charged only when the patient receives at least 30
minutes of critical care provided by a trauma team — but hospitals do not
appear to be following that rule when billing non-Medicare patients.
At the turn of the century
such fees didn’t even exist.
But today many insurers
willingly pay them, albeit at negotiated rates for hospitals in their networks.
Six insurers and industry groups declined to discuss the fees, and a
spokeswoman for America’s Health Insurance Plans, the industry trade group,
said, “We have not seen any concerning trends surrounding trauma center fees.”
Trauma centers argue that
these fees are necessary to train and maintain a full roster of trauma doctors,
from surgeons to anesthesiologists, on-call and able to respond to medical
emergencies at all times.
SFGH spokesman Brent Andrew
defended the hospital’s fee of over $15,000 even though the baby didn’t require
those services.
”We are the trauma center for
a very large, very densely populated area. We deal with so many traumas in this
city — car accidents, mass shootings, multiple vehicle collisions,” said
Andrew. “It’s expensive to prepare for that.”
At what cost trauma?
Experts who’ve studied trauma
fees say that at some hospitals there’s little rationale behind how hospitals
calculate the charge and when the fee is billed. But, of course, those
decisions have tremendous financial implications.
After Alexa Sulvetta, a
30-year-old nurse, broke her ankle while rock climbing at a San Francisco gym
in January, she faced an out-of-pocket bill of $31,250 bill.
An ambulance also brought
Sulvetta to Zuckerberg San Francisco General Hospital, where, she recalled, “my
foot was twisted sideways. I had been given morphine in the ambulance.”
Sulvetta was evaluated by an
emergency medicine doctor and sent for emergency surgery. She was discharged
the next day.
SFGH also charged Sulvetta a
$15,666 trauma response fee, a hefty chunk of her $113,338 bill. Her insurance
decided that the hospital fees for the one-day stay were too high, and — after
negotiations — agreed to pay only a charge it deemed reasonable. The hospital
then went after Sulvetta for $31,250.
“My husband and I were
starting to think about buying a house, but we keep putting that off because we
might need to use our life savings to pay this bill,” she said.
SFGH spokesman Andrew,
meanwhile, said that the hospital is justified in pursuing the bill. “It’s
fairly typical for us to pursue patients when there are unpaid balances,” he
said. “This is not an uncommon thing.”
"I feel like I created a
monster"
Trauma response fees were
first approved by the National Uniform Billing Committee in January 2002,
following a push by a national consulting firm specializing in trauma care. The
high costs of staffing a trauma team available at all hours, the firm argued,
threatened to shut down trauma centers across the country.
Trauma centers require special
certification to provide emergency care for patients suffering very serious
injuries above and beyond a regular emergency department.
“We were keeping an ongoing
list of trauma centers that were closing all over the country,” said Connie
Potter, who was executive director of the firm that succeeded in getting the
fee approved. She now consults with hospital trauma centers on how to bill
appropriately.
Trauma teams are activated by
medics in the field, who radio the hospital to announce they are arriving with
a trauma patient. The physician or nurse who receives the call then decides
whether a full or partial trauma team is needed, which results in different
fees. Potter said that person can also activate the trauma team based on the
consultation with the EMTs.
But reports from the field are
often fragmentary and there is much discretion in when to alert the trauma
team.
An alert means paging a wide
range of medical staff to stand at the ready, which may include a trauma
surgeon, who may not be in the hospital.
Potter said if the patient
arrives and does not require at least 30 minutes of critical care, the trauma center
is supposed to downgrade the fee to a regular emergency room visit and bill at
a lower rate, but many do not do so.
Hospitals were supposed to
come up with the fee for this service by looking at the actual costs of
activating the trauma team, and then dividing it over the amount that their
patients are likely to pay. Hospitals that see a lot of uninsured and Medicaid
patients might charge more to patients with private insurance to make up for
possible losses.
But soon, Potter said, some
hospitals began abusing the fee by charging an exorbitant amount that seemed to
be based on the whims of executives rather than actual costs.
“To a degree, I feel like I
created a monster,” Potter said. “Some hospitals are turning this into a cash
cow on the backs of patients.”
The $15,666 is San Francisco
General’s low-level trauma response fee. The high-level response fee in which
the trauma surgeon is called into action is $30,206. The hospital would not
provide a breakdown of how these fees are calculated.
Unfortunately, outside of
Medicare and state hospitals, regulators have little sway over how much is
charged. And at public hospitals, such fees may be a way to balance government
budgets. At SFGH, the $30,206 higher-level trauma response fee, which increased
by about $2,000 last year, was approved by the San Francisco Board of
Supervisors.
An ibuprofen, two medical
staples — and a $26,998 bill
Some patients question whether
their particular cases ought to include a trauma fee at all — and experts think
they’re right to do so.
Sam Hausen, 28, was charged a
$22,550 trauma response fee for his visit to Queen of the Valley Medical Center
in Napa, Calif., in January.
An ambulance brought him to
the Level 3 trauma center after a minor motorcycle accident, when he took a
turn too quickly and fell from his bike. Records show that he was alert with
normal vital signs during the 4-mile ambulance ride, and that the ambulance
staff alerted the hospital that the incoming patient had traumatic injuries.
He was at the hospital for
only about half an hour for a minor cut on his head, and he didn’t even need
X-rays, CAT scans or a blood test.
“The only things I got were
ibuprofen, two staples and a saline injection. Those were the only services
rendered. I was conscious and lucid for the whole thing,” said Hausen.
But because the ambulance
medics called for a trauma team, the total for the visit came to $26,998 — and
the vast majority of that was the $22,550 trauma response fee.
Queen of the Valley Medical
Center defended the charge. “Trauma team activation does not mean every patient
will consult with and/or be cared for by a trauma surgeon,” spokeswoman Vanessa
deGier said over email. “The activation engages a team of medical
professionals. Which professional assesses and cares for a trauma patient
depends on the needs and injury/illness of the patient.”
Guidelines for trauma
activation are written broadly on purpose, in order to make sure they don’t
miss any emergencies that could otherwise kill patients, said Dr. Daniel
Margulies, a trauma surgeon at Cedars-Sinai in Los Angeles and chair of the
American College of Surgeons committee on trauma center verification and
review. Internal injuries, for example, can be difficult to diagnose at the
scene of an accident.
“If you had someone who needed
a trauma team and didn’t get called, they could die,” he said.
Medics err on the side of
caution when calling in trauma patients to avoid missing a true emergency. To
that end, the American
College of Surgeons says it is acceptable to “overtriage,” summoning
the trauma team for 25-35 percent of patients who don’t end up needing it.
But that logic leaves health
consumers like Jang, Sulvetta and Hausen with tens of thousands in potential
debt for care they didn’t ask for or need, care that is ordered out of an
abundance of caution — a judgment call by an ambulance worker, a triage nurse
or a physician — based on scant information received over a phone.
Jeong Whan had fallen 3 feet
from a hotel bed onto a carpeted floor when his nervous parents summoned an
ambulance. By the time the EMTs arrived, Jeong Whan was “crawling on the bed,
not appearing to be in any distress,” according to the ambulance records. The
EMTs called SFGH and, after a consultation with a physician, transported Jeong
Whan as a trauma patient, likely because of the baby’s young age.
At the hospital, Jeong Whan
was evaluated briefly by a triage nurse and sent to an emergency department
resuscitation bay.
Jang recalls being greeted by
nine or 10 providers at the hospital, but the baby’s medical records from the
visit do not mention a trauma team being present, according to Teresa Brown of
Medliminal, who reviewed the case.
The baby appeared to have no
signs of major injury, and no critical care was required. Five minutes later,
the family was transferred to an exam room for observation before being
released a few hours later. Brown said she would dispute the $15,666 trauma
response fee because the family does not appear to have received 30 minutes of
critical care from a trauma team.
Jang currently has a patient
advocate working on her behalf to try to negotiate the bill with the hospital.
She said she fears that the pending medical debt could prevent her from getting
a visa to visit New York and Chicago, which she hopes to do in the next few
years.
She said her experience with
the U.S. health care system and its fees has been shocking. “I like the USA.
There are many things to see when traveling,” she said. “But the health care
system in USA was very bad.”
