Parents who take their children to the ED for urgent medical attention—often because their pediatrician's office is closed—are increasingly facing "big bills" for "relatively basic medical care," Sarah Kliff reports for Vox.

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Vox in 2017 launched a year-long project to examine how EDs charge patients for medical care. For the project, Vox is reviewing readers' submissions of ED bills from the last five years to develop an ED billing database. In the latest installment, Vox spotlights cases in which parents took their children to the ED for urgent medical attention—often because their pediatrician's office was closed or because the nearest urgent care facility didn't provide pediatric services.

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In one example, Maryland resident Jessica Smart received a $1,375 bill for a roughly 10-minute visit to the ED in which a physician examined her son's ear and gave him ear drops and an antibiotic to treat a severe ear infection. A hospital representative told Smart that $1,075 of the charge was for the two generic medications the boy received, Kliff reports.

In another case, Margot Sroka received a $937.25 bill for a 29-minute visit to a Virginia ED for her one-year-old daughter during which a PA examined a cut on her daughter's toe and applied an antibacterial ointment. The family had tried to avoid the ED, concerned about high costs, but the ED was "the only place to seek medical treatment" for their daughter, Kliff reports—the daughter's pediatrician's office was closed, and Sroka's husband's doctor's office said it was not equipped to treat children.

And in South Carolina, Rita Vlach-Simpson received a $3,100 bill for a visit to a South Carolina hospital ED. During the visit, health care professionals conducted an X-ray and a urine analysis to diagnosis Vlach-Simpson's son with constipation. They did not administer medication. "I was thinking it would be in the neighborhood of $1,000 or $1,200 for an X-ray and a quick doctor visit and urine sample," Vlach-Simpson said. "Then I got the actual bill and it was [around] $3,000."

What drives the high bills

Several factors help explain these "big bills," Kliff reports—including the so-called "facility fee." In addition to charges for medical services rendered, ED bills typically include a fee for using the facility itself. In the Srokas' case, for instance, facility fees comprised $937 of the $937.25 bill—the remaining 25 cents was for the antibacterial ointment.

According to Kliff, EDs have said the facility fees enable ED facilities to be prepared at all times to treat a variety of illnesses, from toe injuries to gunshot wounds. In regard to the Srokas' bill, the hospital that provided care in a statement to Vox said EDs are "costly to operate for a variety of factors." The hospital added, "Centers are staffed 24/7/365 by specialty physicians and nurses trained to treat life-threatening illnesses and injuries. … Emergency centers require specialized technology and life-saving equipment as well as specialist physicians and surgeons to be on site or on call."

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But not all stakeholders agree with that explanation, Kliff reports. Ashish Jha, a Harvard University professor who focuses on health care prices, said, "I'll often hear E[D]s argue that [a] patient isn't paying for their 30-minute visit, they're paying for the fact the CT scanner is on all day, every day. But they'll charge everyone who uses the CT scanner; it's not like those are included in the price."

Citing the Srokas' case specifically, Jha continued, "My first reaction was: This is nuts. … We're talking about a visit that appears to have lasted about 30 minutes. The notion that this generates a charge of $937 is a reminder that [EDs] can charge whatever they want. There is no relationship whatsoever to the actual cost."

Separately, Renee Hsia, a professor at the University of California, San Francisco who studies ED billing, added, "Facility fees are very arbitrary." She continued, "There doesn't seem to be any rhyme or reason to it." In fact, Hsia's research has found that ED bills for common procedures can range from $15 to $17,797—and most of that charge depends on a given ED's facility fee.

Another factor driving these ED costs is demand, Kliff writes: EDs are often the only option available for patients in some cases. For example, both Smart and Jha shared how they or their spouse had taken their children to the ED because their pediatricians' offices were not open at the time their children needed care. In cases like these, Kliff writes EDs have less market competition to keep prices low. As Jha put it, "Markets only work when there are choices. … For most patients and parents in situations like this one, there is no choice."

In addition, the rise of high-deductible health plans also helps explain why U.S. residents are increasingly seeing high ED bills, Kliff reports. In the past, health plans commonly shielded members from the cost of ED visits by, for instance, setting a $100 copayment for an ED visits. Under those conditions, patients never had interactions with facility or service fees—only the copayment. But that's changing with high-deductible health plans, Kliff reports: Despite having insurance, Sroka and Smart are both responsible for the full ED bill, because both of the charges falls within the families' respective health plan deductibles (Kliff, Vox, 4/10).

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