Zuckerberg San Francisco General and the University of California San Francisco are two of the city’s busiest hospitals, about 4 miles apart. But if you have private insurance and visit Zuckerberg General, you could end up paying a lot more for the same treatment.
For an especially serious visit, Zuckerberg General charges a facility fee of $11,176, 46 percent more than UCSF, which charges an average of $7,635.
The hospital is also out-of-network with all private insurance, leaving patients responsible for the fee and the cost of treatment. UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers generally negotiate lower prices for patients, and many plans cover ER visits in part or in full.
Zuckerberg General’s emergency room fees are also higher, on average, than ERs nationally, in the state of California, and in the city of San Francisco. In the city, they’ve charged up to five times as much. The fees are set by the San Francisco Board of Supervisors, which has voted for steady increases, doubling the charge since 2010.
When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.
“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings.
These charges, known as “facility fees,” are the price that patients pay for walking in the door of an emergency room and seeking service. Nationally, these fees are kept secret. Patients only learn their emergency room’s facility fee when they receive a bill after the visit.
Other fees at Zuckerberg General emergency room can be high too. A pregnancy test delivered in the emergency room costs $111, according to multiple bills that Vox examined. One patient who visited the emergency room in 2013 was billed $9.20 for a single ibuprofen tablet.
But the fees to use the emergency room stood out as significantly higher than neighboring hospitals, and important to examine, because they often make up the vast majority of Zuckerberg San Francisco General patients’ emergency room bills.
Patients are paying way more for the same services
We found that privately insured patients seen at Zuckerberg General end up with significantly bigger bills than those seen at other nearby emergency rooms. For example, the hospital charged a $5,369 facility fee for a patient who presents with a “severe” emergency.
Data from the non-profit Health Care Cost Institute shows that the average price at other San Francisco-area emergency rooms is $2,000 — less than half the city hospital’s price.
Bills from Vox’s emergency room billing database, which includes more than 2,000 emergency room bills submitted by readers, tell a similar story.
A review of the 49 bills we’ve received from five San Francisco hospitals shows that Zuckerberg San Francisco General Hospital consistently has the highest facility fees in the area.
“A privately insured patient does not seem to be getting a very good deal at San Francisco General,” says Niall Brennan, the Health Care Cost Institute’s executive director.
San Francisco Department of Health spokesperson Rachael Kagan said that the fees at Zuckerberg General are higher because the hospital is also the city’s only Level I trauma center.
“Our ED [emergency department] is more expensive to operate than other San Francisco hospitals because we are a trauma center,” she said. “Our ED facility fees reflect that.”
The hospital does also charge significant fees to the patients who use trauma services, which range from $17,768 to $30,206 and were covered in a separate Vox story here.
Emergency room facility fees are high — and kept secret from patients
There are 141 million visits to the emergency room each year, and nearly all of them have a charge for something called a facility fee, which, as mentioned, is the price of walking through the door and seeking service. It does not include any care provided.
Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.
Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox is running a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients.
The fees at Zuckerberg San Francisco General turn out to be significantly higher than those at most other hospitals.
In California, for example, average facility fees in 2016 ranged from $416 to $1,172 depending on the severity of the visit. These fees are slightly higher than national averages.
In the San Francisco area, the fees tend to be about 20 percent higher, likely reflecting the higher cost of living in the area. There, the fees range from $326 to $1,713.
But at Zuckerberg San Francisco General, the fees ranged from $463 to $9,853, and often made up a significant portion of patients’ bills.
Nina Dang, a 24-year-old woman treated at the hospital after a bike crash, was billed $11,176 for her emergency room visit. The largest item on her bill was a $24,074.50 emergency room facility fee.
And for Spiros Christakopoulos, a 35-year-old father, the facility fee made up about three-quarters of his hospital bill.
He was taken to the hospital by ambulance last February after falling in Golden Gate Park while carrying his young son, and dislocating his shoulder. He was also charged the same $11,176 fee — the one reserved for the most complex visits — and it made up the bulk of his $15,067.70 hospital bill.
“No one tells you the price,” says Christakopoulos. “It’s the only thing in the world where you go in for something and don’t know the price in advance. But what are you going to do? Die?”
Kagan, the department of health spokesperson, said the fees at Zuckerberg General are “not higher across the board than other trauma centers, as far as I know, depending on what is included in the fees.”
It is true that nearby trauma centers, such the one in Palo Alto run by Stanford University and the one at UC Davis in Sacramento, also charge high facility fees. But those institutions are in network with a wide array of private insurers. Bills Vox reviewed from those hospitals show that the charges are typically negotiated down to a lower price that the patient and insurer ultimately pay.
Speaking to the data that Vox provided, Kagan said, “We haven’t seen these data and can’t tell which hospitals and insurance companies were using in-network, negotiated rates, and which ones weren’t. There are so many variables that feed into those averages. “
The city of San Francisco sets Zuckerberg General’s high prices
The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.
The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”
The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute.
At the time, San Francisco Mayor London Breed was serving on the Board of Supervisors and voted to approve the prices. Her press office did not respond to an email or phone call asking for comment on her vote.
The fees at Zuckerberg General have nearly doubled over the past decade. In 2010, the emergency room fees at the hospital ranged from $287 to $6,118, depending on the severity of the visit. Now the prices range from $525 to $11,958.
But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.
“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.”
Part of the sharp increase may have to do with the fact that the hospital often runs a deficit, with operating costs outstripping the revenue brought in from patient visits. Public financial disclosure documents from the California Office of Statewide Planning and Development show that the hospital lost money in five of the past eight years. Those figures cover day-to-day operations, however, and do not include large charitable gifts — such as the $75 million donation Mark Zuckerberg and his wife, Priscilla Chan, made in 2015.
Those same financial disclosure forms also show that the emergency room is one of the few places where the hospital appears to generate revenue, bringing in more than enough money to cover overhead costs. In other departments, like acute pediatric and psychiatric care, the hospital routinely loses money on the care it provides.
The San Francisco Board of Supervisors now plans to bring greater scrutiny to the hospital’s billing practices in light of Vox’s reporting.
Hillary Ronen, one of the supervisors co-sponsoring the new hearings, voted to approve the hospital prices in 2017. Now, she says, she wants to take a closer look at the issue.
“The department of public health is our biggest general funds department, and has close to a billion-dollar budget,” says Ronen. “This out-of-network pricing just didn’t grab my attention at the time of approving that bill. Now that I’m aware, it’s something I will be looking into and fixing.
Ronen says that she had never received constituent complaints about the issue until last week, when Vox ran a story about the hospital’s billing practices. “After your article ran, it spawned a lot of people to reach out and tell their stories,” she says.
Gordon Mar, a new supervisor who began his term this month, chairs the board’s government oversight committee, and also says he’s “committed” to making sure they investigate this issue.
“Zuckerberg San Francisco General Hospital is our largest public hospital and the only level-one trauma center in the City, and can and should be a place for high-quality, affordable care for all our resident,” he said in a statement. “While we as a City should absolutely seek reimbursement from private insurers, we should not be placing the burden of exorbitant bills on patients – who deserve the highest quality care, not the highest possible costs.”
Nicole Fallert contributed research to this story.