Courtesy of Cameron Fischer
Two days before his wedding last April, Cameron Fischer had a play for a bachelor party, and met some bars in the Old Town of Fort Collins, Colo., With his friends during the wee hours. The next morning, the 30-year-old IT professional from nearby Loveland woke up with a murderer.
"I couldn't hold anything down," Fischer says. "I just felt miserable."
He was in such bad shape that as their wedding day was fast approaching, Fischer's fiancé invited him to leave his rehearsal dinner in Denver and go to an emergency room to be rehydrated.
It resulted in an even bigger headache: a medical bill that was originally $ 12,460, everything told. That was more than twice the cost of their wedding.
Fischer had come across a sobering fact about the US healthcare system. With few restrictions on how emergency rooms set prices, hospital systems have increased prices and coded patient visits as more complex than they would have done before, increasing the payments they receive from insurance plans. The result: ER services have some of the fastest growing prices in healthcare.
Many health economists find standalone ER facilities, such as the one that Fischer visited – which is banned in many states but flourishing in Colorado – particularly punishable. While such ERs claim that they cannot survive on prices paid by Medicare and Medicaid, data suggests that they are profit-seeking engines that are mainly built in high income codes.
"That's because they've figured they can get away with it," says Vivian Ho, an economist at the Baker Institute for Public Policy at Rice University in Houston.
Fischer may have avoided the big bill had he sought treatment earlier in the day. But at 7 am on a Saturday, emergency care facilities were closed. He searched for Google Maps for the nearest emergency room and – stuck in a junk can – went to HealthONE North Suburban Medical Center, a standalone ER in the Denver suburb of Thornton.
ER appeared to be missing patients, with only one physician and a couple of nurses on duty. Fischer told them what had happened and that he did not take drugs and did not drink often.
"I knew exactly why I was there," he says. "It wasn't as if I had any unknown cause for my symptoms."
A nurse started an IV and gave Fischer two bags of saline and one dose of Zofran, a medicine for nausea. She drew blood; Fischer says he was not told what tests would be performed on the blood test. He was outside the ER within 45 minutes and felt much better.
Facility fees as the price of entry
A few weeks after Fischer's April wedding he received the medical bill.
It included a $ 7,644 "facility fee." It is a cost that hospital systems charge to cover their costs of keeping an ER open around the clock and ready for all emergency situations.
The facility fees are set on a scale of 1 to 5, depending on how severe the patient's condition appears during the initial triage. ER rated Fischer's visit as a 4, one of moderately high complexity, when it comes to care needs.
"There are no restrictions on facility fees that they can charge," said Adam Fox, director of strategic engagement for the Colorado Consumer Health Initiative, a nonprofit group for consumer advocacy organizations. says Fox.
The Health Care Cost Institute, an independent, nonprofit health care company, recently analyzed millions of insurance bills to get a better sense of the facility fees that ERs are charging, and found that fees nearly doubled from 2009 to 2016, which exceeded it. In Colorado, the average facility fee for a Level 4 visit increased from $ 1,064 to $ 2,336.
The insurance plans generally do not pay the full fee but pay a negotiated rate for networked hospitals. Improving Value in Health Care, which has a database over insurance payments in Colorado, found that insurance plans paid an average of $ 1,754 for a Level 4 facility fee 2018.
These prices are still pale in comparison to the fee charged to Fischer. "There seems to be a higher exclusion," said John Hargraves, a senior researcher at the Health Care Cost Institute who led the ER study. "That's more than triple what it was in 2016."
Other studies have found that ERs encode visits at higher 4 and 5 levels of complexity with higher prices than in previous years. It is not clear whether this reflects a deliberate attempt by hospital systems to increase payments or a shift in the type of patients visiting emergency rooms. It is possible that the growth in urgent care centers removes less complicated cases.
Treatment costs for a hangover
ER's initial bill included $ 500 for a complete blood count – a test that the online price comparison tool Healthcare Bluebook says there may be less than $ 20 at a surgery . It charged more than $ 1,300 for a complete metabolic panel, a routine test that generally costs about $ 31.
The two liters of saline solution, which ER billed $ 700, are available at Walmart for $ 10.99 per liter.
And spa-like hydration services in Denver Market IV liquids for hangover relief, consisting of the same combination of saline and nausea drugs that Fischer received in the ER, for just $ 168.
The ER bill also included $ 970 for a drug test, something that Fischer says he never approved to undergo. Medicare usually pays care providers about $ 114 for the same test.
"When you look at the bill, the prices are obviously astronomical," Fischer says. "But it was also the work that was done without my permission which was quite frustrating."
HealthONE officials say that the prices of their ERs are higher than in urgent care clinics or other outpatient settings because ER staff are staffed by board-certified emergency physicians and cannot reject any patients, regardless of their ability to pay. So paying patients who show up in their ERS subsidize those who show up and can't pay.
"The move toward higher deductible insurance plans has burdened many of our patients, but we understand their choice to pay a lower monthly premium, and we also understand their frustration over the larger pocket expenses they may experience as a result," the spokeswoman for HealthONE North Suburban Medical Center Betty Rueda-Aguilar in a written statement to Kaiser Health News, adding that Fischer presented symptoms of alcohol poisoning and had to be treated accordingly.The company declined our requests for an interview.
Medical clinics tend to lose money on critically ill patients, as well as on Medicare, Medicaid and uninsured patients, says Dr. Jesse Pines, national director of clinical innovation for US Acute Care Solutions, which helps staff more than 200 hospitals and ERs. These facilities are trying to make the difference with less sick, privately insured patients, like Fischer, say provides Pines.
"In order for the economy of an emergency department to function, patients must subsidize the system to make the difference balance," he adds.
But since more privately insured patients have high deductible plans, he says, it has been harder and harder for hospitals to collect their bills from patients who do not pay.
Free-standing ERs, such as North Suburban, may have found a way to skew their patient mix against those who can pay. A report from the Colorado Health Institute notes that standalone ERs tend to be found in high-income areas. Residents there are more likely to have higher paying commercial insurance, rather than Medicare or Medicaid, and are more likely than other patients to be able to pay for out-of-pocket costs that their insurance does not cover.
Colorado has more than 50 standalone ERs, according to the report, which releases only Texas and Ohio. The facilities are licensed as "community clinics and emergency centers", a designation originally developed to help rural and underprivileged communities in Colorado that otherwise could not afford outpatient hospitals. But the report identifies only eight stand-alone emergency admissions in rural Colorado – all in affluent ski resorts.
For Fischer, negotiated prices during his health plan lowered the $ 12,460 bill to $ 4,694. The plan paid $ 2,102. That left Fischer with a bill of $ 2,593, an amount he says he can't afford to pay.
"It's a pretty expensive bachelor party," Fischer says.
Kaiser Health News is a nonprofit, editorial independent program from the Kaiser Family Foundation and is not affiliated with Kaiser Permanente.