--:-- [Theme music fades out]
--:-- Sean Ramos: Hello. Is this the mysterious Breakmaster Cylinder? It might be. Wow, what an honor.
--:-- Sean Ramos: Hey, this is Sean Ramos from Today Explained. You composed our theme music. I did. Oh, what an honor. The Sean Ramos from. The honor's all ours. Wow.
--:-- Sean Ramos: Hey, quick question for you, Breakmaster. Sure.
--:-- Sean Ramos: I hear you might have mattress problems. I do. So how, however, did you know that?
--:-- Sean Ramos: We G-chat. Oh, yeah, right.
--:-- Sarah Cliff: Welcome back to the show. Thanks for having me back.
--:-- Sean Ramos: You're working on this huge project right now, and it sounds really interesting. And I was wondering if you would share it with the listeners of our podcast.
--:-- Sarah Cliff: In fall 2016, so about 18 months ago at this point, I got this email from a Vox reader who sent me a bill for his daughter's emergency room visit where they were charged $629 for a Band-Aid. A single Band-Aid.
--:-- Sean Ramos: Yeah. Nothing special about the Band-Aid.
--:-- Sarah Cliff: No. And like it turns out you can go to CVS and buy a whole box of Band-Aids for a lot less than $629.
--:-- Sean Ramos: I've heard this.
--:-- Sarah Cliff: The Band-Aid was only $7, which I would say like in any other context, the Band-Aid was only $7. It's an absurd sentence.
--:-- Sean Ramos: But the vast majority of that bill, the other $622, were something called a facility fee.
--:-- Sarah Cliff: Okay. You know, I'd been reporting on health care for seven years at that point. I'd never really heard of a facility fee. I didn't know what it was.
--:-- Sean Ramos: And it turns out it's this usually pretty big, pretty mysterious charge that shows up on all of the millions of ER visits that happen in America.
--:-- Sarah Cliff: And it's actually what makes going to the emergency room pretty expensive for a lot of people.
--:-- Sean Ramos: I'm guessing this Band-Aid facility fee of like $629 is probably on the low end of a facility fee.
--:-- Sarah Cliff: It's actually a great question that unfortunately I would love to tell you the answer to. But one of the things you quickly learn looking into facility fees is that they are kept secret. It's actually really hard to find information about how much these things cost.
--:-- Sean Ramos: That's what this whole reporting project I'm working on is all about.
--:-- Sarah Cliff: So what have you learned since launching the project?
--:-- Sean Ramos: Since launching the project, we've collected about 1,100 emergency room bills from Vox readers all across the country.
--:-- Sarah Cliff: And I'd say I've learned three things. One is that facility fees are basically on every single emergency room bill. There's always some line. It's sometimes called something different. But there's some fee for just going into the emergency room and seeking service.
--:-- Sean Ramos: This is like the base price of going to the ER.
--:-- Sarah Cliff: The second is that these fees are really secret. You won't know what your fee is until you get that bill in the mail. They're not posted somewhere in the emergency room.
--:-- Sean Ramos: Most doctors I've talked to say, I could not tell you what the facility fee is in my hospital that I work at.
--:-- Sarah Cliff: So it's very hard to find out what these fees are. It's not like it's being tabulated there in the ER room.
--:-- Sean Ramos: So probably months before you have an emergency room appointment, your insurance company and your hospital, they sat down and had this big negotiating meeting where they figured out, here's what we're going to pay for appendectomies and for Band-Aids, and here's the facility fee.
--:-- Sarah Cliff: So that's saying also that if you and your husband, for example, have different insurance, you might get two dramatically different bills?
--:-- Sean Ramos: Totally. That is 100% plausible.
--:-- Sarah Cliff: And maybe we got the exact same service. We might go into the emergency room and come out with two very different bills.
--:-- Sean Ramos: And I think that actually gets to, you know, the last thing I've learned from this project is that there's huge variation in the size of these fees, that from hospital to hospital, you could have two hospitals across the street that are charging really, really different amounts.
--:-- Sarah Cliff: You can't call them up and say like, hey, what's yours? There's just such big variation between what different hospitals are charging for what I thought might be a relatively standard item.
--:-- Sean Ramos: So in these thousands of stories you've come across, is there another Band-Aid story in there or something even more absurd?
--:-- Sarah Cliff: There are so many. One thing that stood out to me that I noticed about a half dozen cases of are people who don't get treated in the emergency room, but because they walk through the doors and show up and say, hey, I'm sick, they end up with some pretty significant bills.
--:-- Sean Ramos: So these are people who decide to leave either because they're feeling better or they find out it's going to be out of network. And then a while later, they get a medical bill for walking in the ER and leaving.
--:-- Sarah Cliff: Okay. There's one that really stood out to me, this woman from New Jersey named Jessica.
--:-- Jessica Powell: My name is Jessica Powell. I live in Jersey City.
--:-- Sean Ramos: This is what happens to Jessica. I was in the kitchen, and I apparently blacked out. I knew that this had happened because my ear started bleeding a lot.
--:-- Sarah Cliff: She goes to sleep, but the next day wakes up. It still hurts.
--:-- Jessica Powell: I had gone to an urgent care facility with the injury, and they said, well, this looks like a time-sensitive issue. You should go to the emergency room.
--:-- Sean Ramos: She goes to the emergency room and she keeps asking, is this doctor I'm going to see in my network?
--:-- Sarah Cliff: She's really worried about the medical bills. Like, wait, wait, wait, is this care going to be out of network?
--:-- Jessica Powell: And she said, yes. And I said, OK, that's all I needed to know. I'm going to go find an in-network physician who can see me as soon as possible.
--:-- Sean Ramos: Luckily I was able to find somebody I was discharged No actual care was given other than an ice pack and a bandage to wrap the ice pack around my head
--:-- Sarah Cliff: She leaves with her ice pack and her ice bandage, and that's the visit.
--:-- Sean Ramos: I got a bill from them for $5,751, and that's just the facility fee.
--:-- Sarah Cliff: And her insurance company says, you know, we think this is too much.
--:-- Sean Ramos: Her insurance company pays, I think, $862 to the hospital for this encounter.
--:-- Sarah Cliff: The hospital then, after about a year, starts sending her bills. $4,989.
--:-- Sean Ramos: That was the remaining amount that the hospital said that I owed.
--:-- Sarah Cliff: That's the point at which she got in touch with me about this story.
--:-- Sean Ramos: Sarah did contact the hospital asking about this bill.
--:-- Sarah Cliff: The hospital declined to comment to me about the bill. They declined to comment to me about how they set their rates.
--:-- Sean Ramos: But oddly enough, a few hours later, this was resolved. The entire bill was reversed.
--:-- Sarah Cliff: Amazing. It is, but it's not like a scalable model for managing health care costs in America. Not even a little.
--:-- Sean Ramos: There's only one Sarah Cliff. I would have gone back to the hospital and returned the ACE bandage and the ice pack if I knew it was going to cost $5,000 plus.
--:-- Sarah Cliff: This was one of multiple examples.
--:-- Sean Ramos: You know, I'd say I hope and I think that $5,000 is an outlier, but it can happen.
--:-- Sarah Cliff: And like it did happen to Jessica.
--:-- Sean Ramos: Is there anyone out there that knows to expect these facility fees or does everyone in this country basically go into a hospital sort of blind to them?
--:-- Sarah Cliff: I think we mostly go in blind to them.
--:-- Sean Ramos: And a lot of times that works out OK because most Americans do have health insurance.
--:-- Sarah Cliff: And in most cases, the health insurance is going to pay that fee. And maybe, you know, you'll pay $100 copay or something like that for going to the emergency room.
--:-- Sean Ramos: There are two situations, though, and one of them becoming increasingly more common where it's not really fine.
--:-- Sarah Cliff: One is if you're uninsured, so you're on the hook for the entire bill.
--:-- Sean Ramos: The second is if you have a high deductible.
--:-- Sarah Cliff: So this is the amount you have to spend before your health insurance ever kicks in.
--:-- Sean Ramos: One of the trends we've seen in American health care is deductibles really going up over the past decade.
--:-- Sarah Cliff: As medical prices rise, employers think about how can we keep our contribution down? and one thing they can do is just put on a higher deductible.
--:-- Sean Ramos: Now if I'm in my deductible, I notice the fact that this is actually pretty expensive, that the Band-Aid costs $629.
--:-- Sarah Cliff: How did these facility fees get put into place? Where did they come from? What is their genesis?
--:-- Sean Ramos: When I talk to hospital executives, what I usually hear is that, look, emergency rooms are expensive to run. You need to be open 24-7.
--:-- Sarah Cliff: You have to accept anyone who comes through your door.
--:-- Sean Ramos: Federal regulations actually say that ERs have to provide life-stabilizing care to anyone who shows up, regardless of their ability to pay.
--:-- Sarah Cliff: Does that vary? It doesn't. Essentially, if you are in an emergency room, you are subject to this law called the Emergency Medical Treatment and Labor Act, or everyone in my world just calls this EMTALA.
--:-- Sean Ramos: Is that a character in Black Panther?
--:-- Sarah Cliff: It might. It should be. It should be a character if there's like a healthcare superhero movie. We need that movie.
--:-- Sean Ramos: It's probably the emergency doctor is named Emtala. Emtala. But Emtala basically is this requirement from the 1980s that says emergency rooms have to accept anyone who walks through their doors and provide them with life-saving care.
--:-- Sarah Cliff: They can't say, give us a hundred bucks first. They can't say, let us check your insurance card and then we'll decide.
--:-- Sean Ramos: Yeah. When I talk to hospital executives, the thing I hear again and again is like, well, we have to be ready for strokes. We have to be ready for gunshots. We have to be ready for anything.
--:-- Sarah Cliff: So we essentially create this charge to cover all that overhead.
--:-- Sean Ramos: Yeah. I think that certainly makes sense up until a point.
--:-- Sarah Cliff: But the place where I don't find that argument convincing is the fact that these costs vary so much.
--:-- Sean Ramos: Yeah. It raises some red flags about, you know, what is actually driving those costs.
--:-- Sarah Cliff: Is there a reason that hospitals can't just be a little more transparent about these fees?
--:-- Sean Ramos: I send a lot of inquiries to hospitals where someone sends me a bill and then I write the hospital and I say, I'm writing about this bill. I'd like to ask you some questions about how this price was set.
--:-- Sarah Cliff: Yeah. The response I almost always get is, well, that's a private matter between us and the insurance company.
--:-- Sean Ramos: Those prices are part of a negotiation between a private hospital and a private insurance company.
--:-- Sarah Cliff: And it is built into their contracts that they are not going to talk about what numbers they settled at.
--:-- Sean Ramos: It seems beyond counterintuitive that this care that you received because it was sort of like a life or death situation could ruin your life, could cripple you financially.
--:-- Sarah Cliff: What do we do? Are there solutions?
--:-- Sean Ramos: One of the things, you know, is just giving this information to people.
--:-- Sarah Cliff: Yeah. I would love to see at a hospital front desk, you walk in and there's a sign that says, here's the facility fee if you have Cigna or Aetna or Blue Cross or whatever insurance companies they contract with.
--:-- Sean Ramos: So people know like, OK, this is like the base level and I am aware of that.
--:-- Sarah Cliff: This is something a lot of emergency doctors I've talked to get pretty uncomfortable with.
--:-- Sean Ramos: They worry that people might see those prices go home get sicker possibly die in the worst case scenario
--:-- Sarah Cliff: I don't think the right solution is just keeping people in the dark and deciding that emergency doctors definitely know best.
--:-- Sean Ramos: Like you said those bills can be pretty crippling.
--:-- Sarah Cliff: It's possible some federal regulations would need to be revised to allow this kind of information.
--:-- Sean Ramos: But I think that would do more harm than good for American patients.
--:-- Sarah Cliff: I got a middle ground for hospitals. Don't display what the fee might be for a gunshot wound, let someone go home and just not treat it and die.
--:-- Sean Ramos: But maybe let people know that like an ice pack and a Band-Aid might cost $5,000 so they could just go to CVS.
--:-- Sarah Cliff: Right, exactly. Like that's a case where I feel like Jessica, who we were hearing from before, she would have benefited by knowing up front.
--:-- Sean Ramos: And, you know, when we talked, one of the things she said, which is a kind of sad reflection of the American health care system, because she was really worried about medical bills.
--:-- Sarah Cliff: She told me that, you know, if it came down to going thousands of dollars in debt versus saving my ears, like, it's sad.
--:-- Sean Ramos: But I think I'd choose not to be in debt and, like, lose my ear, which is a really sad statement.
--:-- Sarah Cliff: But I think someone like that who is asking and someone like that who is not in a life-threatening situation, they should have the right to know.
--:-- Sean Ramos: Sarah Cliff is the host of the Impact Podcast here at Vox. If you want to hear more about these ER fees, her show is a great place to start.
--:-- Sean Ramos: Next up, how do doctors in emergency rooms feel about all this?
--:-- Sean Ramos: I'm Ask One in Kentucky. I'm deeply unsatisfied with my mattress.
--:-- Breakmaster Cylinder: Yeah, sure. Wait, hold on. I have one around here somewhere.
--:-- Sean Ramos: A mattress? Yeah. I don't like, you know, sleep like you do.
--:-- Breakmaster Cylinder: But I have one around. Okay, great. Here it is. Okay, listen to this. Okay, this is your mattress.
--:-- Sean Ramos: That's awful. It's got no, it's got, it doesn't slap. you know like listen to this crap hold on there's just nothing there man it's gotta have some resonance right it's gonna have something it's just like it doesn't have enough presence it doesn't have any presence yeah the timber is just all wrong i don't know maybe maybe a firm pillow top kind of thing would give us the the forward momentum your show needs wow
--:-- Sean Ramos: I wonder if they have that at mattress firm.com slash podcast where you can use the coupon code podcast tank to get 10% off your next match was before May 8th.
--:-- Sean Ramos: Wow. Was that all one word?
--:-- Sean Ramos: Today Explained, I'm Sean Ramos for them.
--:-- Sean Ramos: Up top, we heard about how Jessica Pell got billed well over $5,000 for an ace bandage and an ice pack in an emergency room.
--:-- Sean Ramos: We reached out to the American Hospital Association to talk about these fees, but they declined to be a part of this show, so we decided to ask an emergency room doctor.
--:-- Ryan Stanton: Nobody reasonable in health care thinks coming in and getting a band-aid and getting a screening exam is worth $5,000.
--:-- Sean Ramos: Ryan Stanton works in Lexington, Kentucky. R-Y-A-N-S-T-A-N-T-O-N emergency physician and spokesman for the American College of Emergency Physicians.
--:-- Ryan Stanton: So Ryan, you're around these fees. You think and talk about these fees. What's the deal with these fees?
--:-- Sean Ramos: Well, there has to be a facility fee. You have to pay for the room, the supplies, the lights, the water, the nurses, the inspections, the rules.
--:-- Ryan Stanton: I mean, everything, if you slap health care on it, is automatically more expensive. Even if you come in for something that's not a significant emergency, I still had to go to medical school.
--:-- Ryan Stanton: I still have to pay about $25 for every patient who walks in that door for malpractice insurance. I still have to pay to have the nurses there, the lights on.
--:-- Sean Ramos: So the facility still needs a fee to make it available.
--:-- Ryan Stanton: And that's one of the challenges with emergency medicine is it's expensive because we are designed for unstable, sick and dying patients.
--:-- Sean Ramos: I get why we need those fees. But what about like this $5,000 plus fee we heard about in the top half of the show for like an ace bandage and an ice pack?
--:-- Ryan Stanton: That's going to be an outlier. $5,700 or whatever it may be. That's going to be an outlier. That's not going to be the norm across the country.
--:-- Sean Ramos: What about what Sarah Cliff proposed earlier in the show, this idea that hospitals could display a fee structure or something like if you have X insurance, this sprained ankle is going to cost Y?
--:-- Ryan Stanton: Well, no, I don't think it's a bad idea. I just know I can't do it.
--:-- Sean Ramos: The federal law, EMTALA, which came around in the mid to late 80s, says that anybody has the right to seek emergency care no matter their ability or intent to pay, no matter if they're American, whether they're visiting from another country, whether they've got insurance or not.
--:-- Ryan Stanton: I can see how maybe if you posted that a gunshot wound to your upper thigh is going to cost you $15,000 or something like that. Some might go, you know, forget it. I'm going to go ask my cousin Larry to like douse me in rubbing alcohol and pull this bullet out of my leg.
--:-- Sean Ramos: But what about for this person who comes in with a cut on her ear and ends up being charged for an ice pack does it make sense to list some of the facility fees and maybe not all of them at least as some sort of compromise?
--:-- Ryan Stanton: People should know how much things are going to cost.
--:-- Sean Ramos: But to give you an idea of how strict the law is when it comes to that if I have an urgent treatment center across the street I can't post a sign for it in my emergency department that says you can go there because that is considered dissuading you from the emergency services.
--:-- Ryan Stanton: If part of the problem, at least, is this EMTALA thing, where you can't do anything that might deter someone from coming in and using your services in an emergency room, do you think we should just get rid of EMTALA so you can say, hey, a sprained wrist is going to cost you $2,000?
--:-- Sean Ramos: And that way people might be, I don't know, more inclined to go to urgent care down the street or something like that.
--:-- Ryan Stanton: Well, EMTALA may be a pain in the butt for a lot of things, but what it does is it protects every single person on the property of the United States of America.
--:-- Sean Ramos: If you jumped a border and you came here, EMTALA still protects you. If you have no money or if you have money and you have no intention of giving me a dime of it for the care I provide. Imtala still protects you.
--:-- Ryan Stanton: That was the whole purpose of it. It was seen as a need in the 1980s that people were being refused care, denied care, and were having complications and deaths because of it.
--:-- Sean Ramos: And really the thing that pushed it over the edge is pregnant women having babies and nobody wanted to take them because they were uninsured and there was complications and there was deaths to mothers and babies because of it.
--:-- Ryan Stanton: So I think Imtala is very, very important.
--:-- Sean Ramos: Yeah, I mean, but that doesn't really explain why people are getting price gouged for cuts and bruises.
--:-- Ryan Stanton: Physicians don't control health care. Patients don't control health care. Health care is controlled by big business, whether it's big hospital systems, whether it's big contract management groups, whether it's the insurance.
--:-- Sean Ramos: I mean, the profits that Blue Cross Blue Shield announced just a couple weeks ago is enough to pay the salaries of 5,000 ER physicians.
--:-- Ryan Stanton: I mean, we're talking about lots and lots of money, lots and lots of power, lots and lots of influence that have continued to propagate this very challenging and difficult system that makes up a significant proportion of our gross domestic product.
--:-- Sean Ramos: I still just don't understand. When you talk about the cost involved with a Band-Aid and ice pack. You know, as I mentioned, that's an outlier. I mean, you can't keep bringing in the outlier. If that can happen in the system, outlier or not, it feels like something's gravely, gravely wrong.
--:-- Ryan Stanton: Well, it does. Even if it were an outlier, someone in some hospital or some billing agency somewhere looked at a service, which was someone came into our ER, got an ice pack, we sent them home, and still said, all right, let's bill them over 5K.
--:-- Sean Ramos: Who thought that was okay?
--:-- Ryan Stanton: I don't know. And that's what we have to work with the public, with insurance, our providers, and our system as a whole on the transparency to know how much things are going to cost, a fair value to know how much it needs to bill and how much it needs to get paid, and also then helping patients understand access, where they can go based on what they have going on.
--:-- Ryan Stanton: And right now, for many, many in our population, the ER is the only place to go.
--:-- Sean Ramos: It sounds like you don't agree with a lot of the system that you work in, but do you think it's possible to fix it?
--:-- Ryan Stanton: Yeah, I think it has to.
--:-- Sean Ramos: President Obama tried to change our health care system, and it felt like it was the most controversial thing that's ever happened in our government in my lifetime.
--:-- Ryan Stanton: You know, you have to understand the number of people that pull. So in my state, we put up legislation that was going to establish that fair health value across the entire state.
--:-- Ryan Stanton: And the insurance industry came in and just threw out all these scare things and say we're going to have to jack up your bills you're going to have to pay thousands of more dollars per year just to pay for this even though they still reported 1.3 billion dollars of profit just in anthem and blue cross blue shield
--:-- Sean Ramos: So there's folks that don't want to fix it this way you know they're the for-profit industries that want to be able to game the system and if we fix the system they can't game and pull more profits.
--:-- Ryan Stanton: And that is, I think, one of the true crimes of our system is how many groups are profiteering at the expense of the physicians, the providers, the nurses, and the patients.
--:-- Sean Ramos: Ryan Stanton is the spokesperson for the American College of Emergency Physicians. R-Y-A-N-S-T-A-N-T-O-N, emergency physician.
--:-- Sean Ramos: If you or someone you know would like to share your ER bills with Sarah Cliff for her reporting project, head to erbills.vox.com.
--:-- Sean Ramos: Thanks.
--:-- Breakmaster Cylinder: Oh yeah, it's going to be disappointing though. Until I go to MattressFirm.com
--:-- Sean Ramos: Oh no, no, no, sorry. You want to go to MattressFirm.com slash podcast and use the coupon code podcast10 to get 10% off your next mattress before May 8th.
--:-- Breakmaster Cylinder: Oh yeah, totally. What did I say?
--:-- Sean Ramos: Okay, wait, here we go. Ready?
--:-- Breakmaster Cylinder: Uh oh the president just tweeted something incriminating uh oh the economy's doing a thing we don't like uh oh here comes rudy giuliani
