A Baby Was Treated With A Nap And A Bottle Of Formula. The Bill Was $18,000.

Lambert here: “Some hospitals are turning this into a cash cow on the backs of patients.” Imagine my surprise.

By Jenny Gold, Kaiser Health News and Sarah Kliff, Vox

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.

Emergency room bills collected by Vox and Kaiser Health News show that trauma fees are expensive and vary widely from one hospital to another.

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.”

This story was produced in collaboration with Vox, which is collecting emergency room bills as part of a year-long project focused on American health care prices.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Fazal Majid

    This isn’t even a private hospital, it’s SF General (Zuckerberg bought naming rights with a juicy donation, but it’s city owned and run). It’s also the only trauma ER in SF proper.

    1. DHG

      Good thing Fico 9 will no longer take into consideration any medical collection. The med industry is full of crooks.

  2. The Rev Kev

    ”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.”

    I’d dispute that. If it was a small hospital out in the boonies, then preparing for a trauma that may only happen every now and then would be expensive. Being in a big city with multiple car accidents, mass shootings, multiple vehicle collisions and the like you would reckon that there would be an economy of scale at work here which would make it cheaper overall.
    At the prices that this hospital are asking, it would be cheaper to fly their patients to Canada to be treated and then fly them back when they are better. If they are not careful, all these huge sums of money will start to attract the attention of people like Elon Musk to come ‘disrupt’ their scam, errr, industry. Hmmm. The Elon Musk Trauma Center. The mind boggles at the thought of how that would be run.

    1. vlade

      With robots in a yuuuge tent? I shudder at the reworks though (“sorry, we amuptated the wrong arm, have to re-do. But the good news is it’ll be free!”).

    2. PlutoniumKun

      Exactly so – maintaining trauma and emergency services in small towns and rural areas can be very expensive per patient served – but in a big city hospital the marginal cost of every additional patient, no matter how badly injured is negligible. A friend of mine is an emergency room consultant in a large hospital, in theory he is often on call when not present, but in reality he says peaks and troughs of demand can be handled through normal staffing arrangements.

    3. lyman alpha blob

      All patients would be picked up by a drone and delivered to the nearest station of Musk’s pneumatic tube network, at which point they would be shot at 200 mph through the tube straight to the nearest hospital bed to be operated on by the beta version of Elon Musk lookalike cyborgs.

      If the patient survives, treatment is free. Die and Musk gets your life savings. That sounds about right.

    4. rd

      It has finally attracted the attention of Amazon, Berkshire Hathaway, and JP Morgan: https://www.geekwire.com/2018/atul-gawande-starts-first-day-ceo-amazon-berkshire-hathaway-jpmorgan-health-venture/

      Since I moved to the US in the 80s, the most baffling thing has been the lack of interest Corporate America has expressed in controlling its healthcare insurance costs. This recent consortium may be the indicator that corporate America will start to do something coherent to manage costs.

      The argument against things like Medicare-for-all is that competition and the private sector will create an efficient market place. There has been no evidence that this is actually occurring over the past 30 years.

      1. cnchal

        You crack me up.

        . . . This recent consortium may be the indicator that corporate America will start to do something coherent to manage costs.

        Three of the greediest organizations on the planet gang up and ride to the rescue. Were you a drowning man, you would be better off catching the anchor and drown with it than trying to survive in the hellhole these three have planned for you.

    5. Niel Malan

      Indeed. From a total cost point of view it’s cheaper to use airlift to urban trauma centers than to maintain trauma centers in rural areas.

  3. For_Christs_Sake

    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.

    I hope the author does a follow up to this article. My top concern is whether Jang is able to visit Chicago and New York in the future. /s

    1. oh

      I recommend Jang offer the hospital $5 in full payment. If they refuse the offer they get nothing. BTW Jang, do you really want to come back for more? Hospitals in Chicago and New York may charge even more!

  4. Tinky

    I’ve mentioned this previously, but for (blinding) contrast, last year I went to a high-quality, private health clinic in Lisbon, Portugal, to have a cut/scrape treated. After having received roughly 20 minutes of fine care, along with a supply of good waterproof bandages, I stood at the register, blinking at the bill: 6 Euros. That’s six Euros.

    1. swap

      Along similar lines, wife and I were in Thailand about a year ago and she developed a UTI. Having had a frightening episode of same on a long ago trip, decided medical attention was called for.

      Hotel arranged for transport to a nearby hospital. An exam was done by a very nice doctor, a culture was run, and an antibiotic was prescribed and filled right there at the hospital.

      With considerable trepidation, I waited for the bill…

      450 baht. At the then exchange rate, about $15.

      We’re exceptional all right.

    2. Whippoorwill

      I was super sick in eastern Peru a few years back. I didn’t even think of going to the hospital, but the hostel owner finally dragged me there herself (even paid for the ride, among other generous help). Turns out I had nasty malaria, where the onset had been masked by heat exhaustion, plus some unnamed (or I maybe I didn’t know the Spanish word) liver infection. Several hours in a hospital, review, shots, a course of 1x/day visits for many pills/day for ~2 weeks, and guess what?

      Total cost was the equivalent of about ~$3.

      Oddly, at one point the sent me from the waiting area to a record-keeping area and directed me to pay for my own manila envelope for my record. That cost was included in the total $3 I cited above.

      That $3 doesn’t include water or toilet paper, which are not provided in the hospital. They expect you to have family that brings those things. The hostel owner phoned her daughter who took over, and the owner brought me those things. I took her and her daughter out for dinner after I recovered in thanks.

  5. Thuto

    WTF, it wouldn’t surprise me to learn that the field workers are incentivized to call in for trauma activation even when their judgement obviates the need for it (with some cream off the top of that mountain of cash being funneled their way). It’s the chasm between a qualified trauma physician’s call on what constitutes a life-threatening emergency (a call not available in an ambulance) and that call being above a low level ambulance field worker’s pay grade/expertise (and the extremely low margin of “judgement call” error inherent in such situations) that is being monetized to the hills here. I’m surprised the article doesn’t mention good ole corruption as a possible underlying driver of this rapacious scheme.

  6. Carl

    I wonder how many of these kind of articles have to appear before the US healthcare system is forced to change. Oh wait, the exact number is unclear, but it approaches, apparently, infinity.

    1. Spring Texan

      Yep, makes no difference, the tolerance for grift and price-gouging is . . . INFINITE.

  7. Mark

    Recommend to everyone to read Elisabeth Rosenthal’s “An American Sickness”


    Most of the book is an excellent history of how thing’s got this way but their are some very, very useful appendices that help one to avoid some of the worst of these outrages. One very simple thing is (if you are lucky enough to have insurance) always go to your in-network hospital and never, never, never simply sign the consent forms as given to you. You would be surprised how many of the docs and other service providers at your in-network hospital are out-of-network and will send you outrageous bills for stuff you thought was covered.

    So write the following on every page of the consent form requiring a signature (and tell your loved ones to do it for you if you are in a situation where you can’t do it yourself):

    “Consent is limited to in-network care only and excludes out-of-network care”

    and then sign.

    Wouldn’t have helped this family but it would have helped, for example, the family that got a >$50k bill from the out-of-network neonatologists after their triplets were born prematurely.

    Also there is some good advice re: ER care here (I’ve read that few if any ER doctors are part of any network so that they can bill separately).


    1. emorej a hong kong

      “Consent is limited to in-network care only and excludes out-of-network care”

      Even safer: tattoo this on your chest.

    2. Kathryn Bambrick

      Problem with this is that if the out of network docs are the only ones available to care for your triplets or whoever, you are out of luck, not just out of network. universal health care with no network only solution.

  8. John Zelnicker

    Back in 1971 traveling with my girlfriend in Norway, she broke a tooth. We found a dentist who spoke English (as do most Norwegians) and she had a root canal with a temporary cap. It took about 25 minutes and the dentist apologized for having to charge twice the normal price since we were tourists. The total was $9.50. That evening we met a couple just in from the US and he had the same procedure shortly before they traveled and it cost him $225.

    The temporary cap lasted for at least 4 years.

    1. marym

      Thanks for the update. Combining issues like M4A with medical debt forgiveness, or tuition-free public college with student loan forgiveness seems worth considering.

  9. annie

    in italy, where i live, emergency care is free. i met a woman from south africa last year who’d had appendicitis while vacationing on the amalfi coast. an ambulance took her off the coast to a big city hospital where she was operated on and stayed for six days. when she said, ‘what do i owe?’ the answer was, ‘nothing: it was an emergency.’

    1. oliverks

      My mother fell and broke her hip in Sicily 5 years ago. It was a really bad break, the entire top part of her leg bone disintegrated. She needed an ambulance ride, complex surgery, a special part order from Germany, and physical therapy (3 weeks in hospital).

      I would describe the quality of care as excellent. They were slower than the US, but they seemed to get stuff right when they did it. For example, there was some planning that went into what type of replacement they were going to do, and what part, and making sure she met all the right protocols.

      Amazingly she was off pain killers as soon as the operation was over. She was given no antibiotics (and suffered no ill effects). She was treated well by the staff who often had limited English.

      The total bill was 10,800 Euros with no insurance. I believe the hotel where she fell picked up the tab.


  10. mondo

    I recently visited an urgent care clinic to have some minor cuts/scrapes treated (I thought one cut might have needed stitches). A PA looks at my cut for 5 minutes and tells me I don’t need stitches. I later get a bill for a level 4 outpatient service ($165).

    This is what a level 4 service should look like:

    at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

    I work in healthcare IT myself, so examining my patient record further, I noticed half the dictation text is carry-forwards from previous previous visits and most of the detailed examinations weren’t even done. I raised a stink with my insurance carrier and the urgent care clinic and got the bill canceled. Still, this sort of billing behavior makes me hesitate whenever I feel I should visit a doctor or clinic in the future.

  11. Aleric

    Maybe there needs to be a ‘just stop paying’ movement for these outrageous bills. How vulnerable are these places if the cash flow slows?

    1. Carl

      I am only guessing here, but there might actually be a benefit to living in Texas regarding this. Specifically, there are provisions in the Texas Constitution that prohibit recovery from 1. your house (homestead) 2. your clothes, tools, etc. I think this means that most people here are considered “judgment proof,” and medical billers don’t bother trying to do much to collect unpaid medical bills. I’m not going to go into personal details here, but my experience is consistent with this, and not for small amounts either.

  12. rps

    Zuckerberg’s SF General is a NPO hospital- 501(c)3 charitable support organization. Jang Yeo Im should demand charitable care at no cost since SF General is mandated to provide such care by the IRS 501(c)3 provision.

    Like the majority of big city NPO hospitals, SF General is no more than another generous tax write-off for Zuckerberg and his buddies ‘donations’. The Zuckerberg San Francisco General Hospital Foundation website states it plays a critical fundraising role, established as an independent 501(c)3 charitable support organization.

    Provisions Unique to 501(c)(3)
    One of the most distinct provisions unique to Section 501(c)(3) organizations as compared with other tax exempt entities is the tax deductibility of donations. 26 U.S.C. § 170, provides a deduction, for federal income tax purposes, for some donors who make charitable contributions to most types of 501(c)(3) organizations[2].

    Other unique provisions tend to vary by state. Like federal law, most states allow for deductibility for state income tax purposes. Also, many states allow 501(c)(3) organizations to be exempt from sales tax on purchases, as well as exemption from property taxes.

    From the Washington Post: “Tax breaks for hospitals have been a highly contentious policy point in the health-care world. The most recent data show that nonprofits received about $24.6 billion in tax breaks at all levels of government in 2011, a number which has skyrocketed over the past decade.”

    Bottom line- NPO hospitals are not held accountable in providing a mandatory percentage toward charitable care. Instead they usually provide no more than 1.9% in ‘charitable’ care versus For-Profit hospitals which provide 1.5%.

    Currently, Congress and state critters are terrified of reigning in these NPO entities who truly don’t serve the community. Rather, they don’t contribute to the communities in paying their fair share in taxes and provide negligible charitable care. And in turn, the tax freebie burden is shouldered by the residents with higher property and sales taxes. Either federally mandate charitable care requirements an equitable percentage of the 501(c)3 charitable support organization’s tax exempt freebie or abolish it.

    Frankly, it’s another boondoggle for the self designated saintly parasites such as Zuckerberg.

  13. roxan

    In 1986 I was visiting England when I fell down the stairs and ripped tendons in my foot. The hospital sent 4 guys in elaborate doorman-like uniforms and a giant van that could have carried a dozen patients! They insisted on carrying me to it. When I went to pay the ER bill I was so shocked–the receptionist said, “Oh, no my dear. We wouldn’t dream of charging you. You’re a guest in our country.”

    1. Spring Texan

      That’s how it worked till recently. My brother had a similar experience on a visit 10 years ago.

      Now, the Tories want foreigners to pay and that of course means they are demanding extra paperwork from Brits especially immigrants and giving them problems also.

      Nye Bevan is turning over in his grave.

    2. Lord Koos

      A friend of mine, an American citizen, was travelling across Canada by train when he came down with a bad flu. They took him off the train and put him in the hospital for a few days until he improved, no charge.

    3. Jean

      On Netflix there’s a great British TV series called “An Hour to Save Your Life” about London E.R.s and the fabulous care they give under the NHS, which I assume is still free.

  14. Roger Smith

    Hah! Nothing like the perfect souvenir from the “Greatest Country” on the Planet (TM). What freaking joke this place is.

    Notice how the hospital claims that it is not uncommon to pursue unpaid bills. Of course not, it is the inflated charge that is the issue!!

  15. Ape

    I don’t understand. Why would a South Korean family pay a US bill? Why even bother and why would the hospital even pay the stamp?

  16. JimTan

    Excellent post Lambert.

    I think the main reason for this improper overcharging is that our U.S. healthcare system mostly prohibits any negotiation for the price of its services. In our current healthcare system, patients are customers who must always consent to receiving the service of medical care before they are notified of its cost. As a result medical providers can charge whatever they want. Technically a medical provider can choose to price their services at reasonable value and profit over cost, but in this system there are few mechanisms to prevent massive overcharging once the customer has consented to receive services a doctor determines are necessary. Government insurance programs like Medicare, because they are explicitly prohibited from negotiating prices, greatly magnify this problem.

    So according to your post hospitals can now overcharge for services they are prepared to offer a patient, even if a doctor determines after examination that they are not required for treatment. I’m no economics expert, but this doesn’t seem remotely related to the transparent market systems which more efficiently resolve price discovery in other sectors of our economy.

  17. Schmoe

    I recently had my first encounter with an ER (actually two visits) for an intestinal blockage. On my first visit I was given a CT scan – probably unnecessary since the blockage appeared on an X-ray given before the CT scan and they were not intending to operate. I was discharged four days later but the blockage remained and I was back in the ER after another four days.

    During the second visit the physician insisted I have another CT scan; I asked why he could not use the first one and he never answered, buyt basically said if you want to be treated you need to have it done. I asked for an MRI instead but he insisted on a CT scan. I unfortunately relented, got another massive radiation dose and as expected it showed the same blockage in the same place. But . . . they then decided I needed an MRI instead so I had that done. The reimbursed costs of the second CT scan and MRI were $11,000 in the aggregate. They did absolutely nothing for my treatment since the blockage eventually passed on its own and there never was any consideration of surgery.
    Based on how vehemently second doctor pushed for the second CT scan, I have no doubt that he was being monitored on how many tests he ordered.

    1. Jeff Fisher

      You are not going to fix this by anything that relies on regular humans in crisis to successfully negotiate ideal transactions with expert corporations. There is no solution in that direction, ever.

      1. JimTan

        I agree that I sure wouldn’t want to negotiate with a doctor at the critical moment I’m being wheeled into a hospital emergency room. Choosing a subscription to the best value medical services based on transparent prices can probably be accomplished long before any medical care is needed. My above comments are simply an observation that healthcare costs can be outrageous because these transactions fundamentally lack a price negotiation. This is in contrast to other industries which maintain stable and reasonable prices because of their market based transparency. Hospitals and doctors will frequently overcharge when customers agree to buy healthcare before we are told how much to pay for it. This would probably be true for any other industry or business sector with the same rules.

        Since medical care is essential, and something I believe should be considered a human right, I personally support Medicare for all as the best solution to this problem. The long term costs of this type of program will only be sustainable, however, if prices are transparent and negotiated to accurately reflect the value and costs of services delivered.

  18. Allegorio

    The professional classes in this country are corrupt to the core. Rife with careerism elitism and greed, down to the universities that train them. The Great American Greed Machine at work. Years ago I launched my scooter into the air over a unseen speed bump, came down on my back. Broken collar bone some broken ribs, about a month of painful getting in and out of bed. I was asked if I wanted an ambulance, I knew better. No emergency room for me. I have come to the point where I would rather die than submit to this barbarian medical system.

      1. Schmoe

        See my intestinal blockage comment elsewhere. On my second admission, I tried to bypass the ER by asking for direct admittance to a hospital bed as the diagnosis and treatment protocol were clear and did not require an ER. Didn’t work – I was told I had to pass through the ER to get admitted.

    1. Anarcissie

      Yes! Once you merely call for an ambulance, to say nothing of getting into one, you lose control of the situation and the local operatives of the Medical Industry can charge anything they want. Give up control of yourself only at the last possible moment, and only in the most restricted possible way. Remember that you are in the presence of major predators. Many horror stories, but I think you’ve heard them already.

  19. Jean

    Doesn’t commercial law prohibit the enforcement of a contract if the terms are not named beforehand?

      1. Anon

        I feel like there’s also an unconscionability defense possible to at least get the uninsured rate down to something more in line with what Medicare or other insurers pay.

  20. Jeff Fisher

    I’ve been to the ER almost half a dozen times in the last few years, and while the bills from the hospital have often been quite high the only clearly absurd one was for a 30 minute ambulance transfer from one hospital to another (for overnight observation at the latter) at $7000. Insurance paid a bit under $1000. Ambulance company came after me for the rest, but dropped it by $2000 after 20 minutes on the phone if I paid cash today! Probably could have lowered it more with a protracted fight and by hiring an expert bill-arguer. Felt very much like buying a used car from a disreputable dealer.

    America: the one country where ‘medical bill negotiator’ is a profession.

  21. Jeff Fisher

    Health insurance in the US these days is riddled with holes, even if you don’t have a high deductible.

    You’ll often read comments from people about how they have chosen some high deductible option and wish they could buy less comprehensive coverage because they oh-so-wisely keep reserves so that they can easily pay that deductible. These people have no idea how it actually works. Even if you had no deductible at all you can easily face many thousands in out-of-pocket bills. And whatever your deductible is you can still face many thousands of out-of-pocket bills on top of it. And you don’t have to have some dramatic-double-ER-episode problem to get there. You might not even stay overnight at the hospital.

  22. EoH

    But, but, but, but if patients only had more skin in the game, they would be more demanding of medical service providers and put a brake on all these absurd charges. It’s the patients’ fault.

    We get the skin in the game, but not much else besides a higher bill. Somebody’s laughing and it ain’t us.

    1. Angie Neer

      “Skin in the game” has an especially sinister resonance in the context of health care.

    2. Ape

      People have literal skin in the game and the mc’s want still more.

      It’s insane. Real skin is never considered by the ideologues.

  23. Andrew Dodds

    I got a week’s intensive care, multiple procedures and an operation, two weeks on a ward, physiotherapy at home, masses of prescriptions, 12 rounds of chemotherapy and plenty of follow up appointments over 2.5 years..

    No fees thanks to the NHS (apart from £10/month for prescriptions).

    1. Visitor 239

      When my wife developed alopecia in our little county with a publicly-funded health service, not only were her doctor’s visits and referrals to various specialists ‘free’ – at least to her – the system even subsidised the cost of a couple of wigs to ease the feminine ‘trauma’ of her going into town with an unsightly scalp.

  24. Carl

    More broadly, there’s a good reason that all these “neighborhood” ER clinics have sprung up in my town, operated by the big hospitals (San Antonio has a large medical complex). ERs are a huge source of profit for hospitals, and so why not branch out a bit? Along with that, of course, comes the balance billing and outrageous (legally speaking, “unconscionable”) fees. Predatory comes closest to describing US healthcare, although I do like the late Uwe Reinhardt’s phrase, “a system designed by the devil.”

  25. Pat

    Once again having everyone but the end user write the laws has led to a situation where the public gets bilked multiple times by multiple crooks. And I don’t just mean the patients over billed by the Hospital or ambulance service or the….
    Nope, we get in taxes unpaid, increased administration bills and costs, bad will with tourists, but even more so with an increasingly unhealthy population.

    If I believed in it, I would wish the Eighth level of hell upon on everyone with making ACA the only version of so-called health reform, everyone blocking Medicare for All, everyone trying to destroy the NHS and everyone seeking to profit or get a tax break for false charitable health care services. Please feel free to add on anyone you can think of who is essentially trying to pay for their gold bathroom taps by ripping sick people off.

    (Frankly I think if Dante were around he would invent a couple of more levels just to acknowledge our centuries advances in means of corruption and perfection of long distance destruction of all types.)

  26. ObjectiveFunction

    This will be old hat to NC regulars, but:

    ‘One family illness away from ruin’ is emerging as a key class divider, distinguishing the insured (and credentialed) “top third”(?) of households from the precariat beneath.

    Medicare, Medicaid and VA somewhat blunts the blow for maybe half this group? (so another 1/3 say?)

    Which leaves a third of working age American households fully exposed to the rapacious health machine. Temps, clerks, plumbers, shopkeepers.

    As if unaffordability of housing in places with job options and decent schools wasn’t bad enough. And as for higher ed….

    (feel free to correct my ‘numbers’)

  27. Tyronius

    I’m not shy to admit that I have hidden my income and finances as much as possible. No loans, no bank accounts, no credit cards, no checking accounts, no W-2. I look like a pauper ghost when my credit is pulled. The last time I went to hospital in America I simply said I was indigent. ‘sue me and you’ll get nothing but legal bills’, was how I put it. I never saw a tab lol

    Was it dishonest? No more so than gouging the sick…

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