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Margot Sroka, 1, with her mother Becky near her home in Sterling, Virginia.
Kainaz Amaria/Vox

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Toe ointment, a $937 bill, and a hard truth about American health care

“My first reaction was: This is nuts. There is no relationship to the actual cost.”

Last October, Bradley Sroka took his 1-year-old daughter, Margot, to the local emergency room. The little girl had managed to tie a piece of her own blonde hair around her toe, causing it to swell and turn purple.

The hair had left a clean circular cut around Margot’s toe, which spurted blood each time her parents tried to inspect it.

“We had no idea how deep the cut was, whether we could just wrap a Band-Aid around it,” Sroka says. “It was like nothing we’d ever encountered.”

Margot turned out to be fine — a physician assistant inspected her toe, made sure the hair was gone, and applied an antibacterial ointment.

A month later, the Sroka family got the bill: $937.25 for the 29-minute visit. They are responsible for the entire bill, which was within their deductible.

Bradley and Becky Sroka, with Margot, 1, near their home in Sterling, Virginia.
Kainaz Amaria/Vox

The Srokas tried to avoid the emergency room because they knew it would be expensive. But it was a Saturday, and Margot’s pediatrician office was closed. They did take her to Bradley’s doctor office, which was open, but staff there determined that they weren’t equipped to deal with tiny toes. The emergency room was the only place to seek medical treatment.

“At the time, I just had no idea how to treat it,” says Sroka. “The emergency room was our only option.”

“For most patients and parents, they’re in situations like this one, there is no choice”

The Srokas submitted their bill to Vox’s ER Billing Database, a year-long project that explores how emergency rooms charge for care. If you have an emergency room bill from the past five years that you’d be willing to submit, you can do so here.

To date, Vox’s ER billing project has gathered 1,157 bills from all 50 states and Washington, DC.
Kavya Sukumar/Vox

The Srokas’ bill is among many that fit a pattern: Worried parents took their children to the emergency room because their pediatrician’s office was closed, often on the weekends or at night. Some tried to go to urgent or immediate care facilities but were turned away because those offices often do not provide pediatric care.

When these little patients were treated in the ER, even for relatively basic medical care, their parents then received a big bill. Even families with insurance submitted bills that left them on the hook for hundreds or thousands of dollars, a burden for most typical American households, and doubly frustrating because the treatments weren’t complex.

Our database includes the story of a 2-year-old boy who received IV hydration and three over-the-counter medications at an emergency room — and then received a $2,400 bill. We heard from a mom whose 9-year-old son received a $3,100 bill from a South Carolina hospital, which used an X-ray and urine analysis to determine that he was constipated. No drugs were administered in that case. The family is currently paying off that bill $50 each month.

“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,” Rita Vlach-Simpson, the parent who sent in that bill, says. “Then I got the actual bill and it was $3,000.”

Only in America

These cases fit what experts describe as one of the defining features of the American health care system: exceptionally high prices for routine medical services that would typically cost much less in peer countries like Canada or France.

Vox asked Ashish Jha, a Harvard professor whose research focuses on health care prices, to review selected bills, including the one submitted by the Sroka family for their 1-year-old daughter’s toe injury.

“My first reaction was: This is nuts,” Jha said. “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 [emergency departments] can charge whatever they want. There is no relationship whatsoever to the actual cost.”

Inova Hospital System, which owns the facility where Sroka was seen, sent me a written statement regarding the charges. It noted that emergency rooms are “costly to operate for a variety of factors,” and those expenses get factored into their patients’ visits.

The Sroka family paid nearly $1,000 for a 29-minute emergency room visit.
Kainaz Amaria/Vox

“Centers are staffed 24/7/365 by specialty physicians and nurses trained to treat life-threatening illnesses and injuries,” Inova’s statement reads. “Emergency centers require specialized technology and life-saving equipment as well as specialist physicians and surgeons to be on site or on call.”

Jha recently published a paper in the Journal of the American Medical Association exploring the key drivers of America’s sky-high health care cost. He shows that Americans go to the doctor roughly the same amount as people in other countries — we just pay more for each visit, hospital trip, or drug.

This seems to be especially true in emergency rooms, which are open when other doctors’ offices are closed — and charge a premium for their services.

“Markets only work when there are choices,” Jha says. “For most patients and parents in situations like this one, there is no choice.”

In the emergency department, ear drops can cost more than $1,000

Most emergency room bills have two components: the services provided, and a fee for using the emergency room itself. Both can vary dramatically from hospital to hospital and add up to significant bills for patients.

In January, Jessica Smart took her 7-year-old son, Kylan, to the emergency room for a severe ear infection. “I usually try to avoid the ER as much as possible,” Smart, 34 and a mother of four, says. “We went because there was blood in his ear and that is not normal.”

Jessica Smart and 7-year-old Kylan Smart near their home in Frederick, Maryland.
Kainaz Amaria/Vox

Smart estimates that they spent about 10 minutes with a doctor, who checked Kylan’s ears and gave him some ear drops as well as an oral antibiotic. The fees for those two generic drugs came to $1,075, a hospital representative told Smart — which was the bulk of the $1,375 bill. The Smarts are responsible for the entire payment, which falls within their health insurance deductible.

“We pretty much make enough to live; we don’t have a big savings account to dip into,” Smart says. “It’s frustrating they’re allowed to charge me whatever they want.”

In the Smarts’ case, the big bill was because of the drugs. For the Srokas — the family worried about their young daughter’s toe — it was high emergency room fees.

Jessica Smart’s ER bill totaling more than $1,300 for a 10-minute visit.
Kainaz Amaria/Vox

The hospital where 1-year-old Margot Sroka was seen charged only 25 cents for the ointment a provider put on her toe. It billed an additional $937 for a “facility fee,” the price of walking through the door and seeking care.

These facility fees are typically kept private — patients don’t see them until they receive a bill — and vary significantly from hospital to hospital.

“Facility fees are very arbitrary,” Renee Hsia, a professor at the University of California San Francisco who studies emergency billing, previously told Vox. “There doesn’t seem to be any rhyme or reason to it, which can be really frustrating. There are some places where the basic facility fee can be over $1,000.”

One of Hsia’s studies on ER bills for common procedures showed that prices can vary from as little to $15 to as much as $17,797. And a lot of that depends on the given hospital’s facility fees.

Hospitals argue that their facilities need to be ready to treat anything that comes in their door, whether it’s a toddler’s toe injury or a life-threatening gunshot wound. This was Inova’s explanation for Margot’s toe and is a common defense I’ve heard before from hospital executives.

Jha, the Harvard professor, disagrees with this argument.

“There is just not a justification for these prices,” he says. “I’ll often hear ERs argue that this type of 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.”

“We don’t have a big savings account to dip into”

Health insurance plans have typically insulated most patients from their emergency room bills. If a plan, for example, has a $100 copayment for an ER visit, then the patient never really interacts with the facility fee or specific drug charge. She pays the copayment and nothing else.

But that’s increasingly not the way American health care works. Deductibles have risen steadily over the past decade, meaning that patients are more likely to bear the full brunt of their health care bills. That’s what happened to the Smart family; their son’s ear infection visit was January 8, and the entire charge fell into their deductible.

Jessica and Neil Smart with their children Ryder, 9, Kylan, 7, and Iyla, 9 months (left to right) in their home in Frederick, MD. Not pictured: Nyah, 12.
Jessica and Neil Smart with their children Ryder, 9, Kylan, 7, and Iyla, 9 months (left to right) in their home in Frederick, Maryland. Not pictured: Nyah, 12.
Kainaz Amaria/Vox

Smart takes care of her four children (the oldest is 12, the youngest is 8 months) and works two part-time jobs as a dance teacher and fitness instructor. Her husband owns a small car-restoration business, which she says they’ve put most their savings into. They do not currently have the cash on hand to pay their $1,375.88 bill.

“I feel trapped,” Smart says.

After Vox inquired about the price of the Smart family’s visit, the hospital where Kylan was seen put the bill under “financial review.” What that means is not yet clear.

The Srokas were also in their deductible when they received an emergency bill and had been trying to push back on the charges — but so far have had no luck.

“I can’t call off hours because they’re closed, so I have to call in the middle of the workday, and I often don’t have the time to do that,” says Sroka, who works for an IT company.

The Sroka family’s bill went into collection as Vox was reporting this story. In early April, the family decided to go on a payment plan. They will pay approximately $130 each month for the next seven months, until the bill is paid off.

Both Sroka and Smart felt like they made the right decision to take their children to the ER. Their children weren’t necessarily having an emergency, but there was nowhere else to go on the weekend or in the evening to receive necessary treatment.

Jha said he could relate. Two years ago, his 9-year-old daughter complained of being short of breath. She seemed to need a new inhaler, but her pediatrician’s office was closed and the nurse’s hotline wasn’t comfortable issuing an inhaler prescription without an in-person visit.

Jha’s wife ultimately took their daughter the emergency room, where the family received the inhaler. It wasn’t an emergency, but even for a Harvard professor, it was the only option available on a weekend.

“I remember thinking, what a complete waste — but the problem was we didn’t have any alternatives,” Jha says. “I’m very sympathetic to parents who, faced with uncertainty, are going to do what feels safe for their kids, who need a place for their kid to be seen.”

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