For more than a year, Vox's Sarah Kliff has been investigating hospital price-gouging in America, collecting hospital bills from her readers and comparing them, chasing up anomalies and pulling on threads, producing a stream of outstanding reports on her findings.

In her latest installment, Kliff digs deep into the famously bizarre world of ER bills and points out some of the most egregious ways in which these are rigged.

For example, if you are injured and also financially precarious, you might travel to a more distant ER just to be sure that the hospital you're visiting is in-network for your insurer, but that means nothing. "In-network" ERs often staff "out-of-network" doctors, and there is no way to find out whether the doctor treating you is covered by your insurer until you get the bill: one of Kliff's readers got bills for $8,000 from an out-of-network surgeon who treated his broken jaw at an in-network hospital.





And much of the care you receive at an ER is subject to bizarre price gouging: one of Kliff's readers was charged $238 for two drops of the generic eyedrop ofloxacin which retails for $15/vial; the routine pregnancy test that ERs administer to women of childbearing years can cost up to $465, enough to buy 84 pregnancy kits at the pharmacy; and one Seattle hospital charged $76 for a squirt of generic neosporin. Not all hospitals gouge on all drugs, and many of these drugs are not being administered for urgent health problems — a halfway honest hospital could advise a patient, "We charge $238 for this eyedrop, why don't you pick up a bottle for $15 next door and administer it yourself?"

Finally, Kliff uncovers wild variability in the "ER facility fee," which is a cover-charge you're assessed just for walking in the door at an ER. One of Kliff's readers paid $5,751 for sitting in a hospital waiting room with an ice-pack and a bandage while waiting to see a doctor, but who left because she was feeling better and didn't need care after all. Kliff's work reveals that these "facility fees" are rising at twice the rate of other health charges, with no rhyme or reason.

All of this refers to people who come into the ER under their own power, out of an abundance of caution — for example, my daughter recently broke her collarbone, but we didn't know that until we went to the ER for an X-ray, and if we'd less prudent, we could have iced it and made a regular doctor's appointment for the next day, leaving her untreated and undiagnosed. But of course, ERs treat large numbers of people who are unconscious or in agony when they arrive, either on their own or on an ambulance gurney. These patients can't possibly be expected to shop around, to demand to know whether their medicines are medically necessary (I once had a small eye injury that I went to get checked out on a Sunday just in case and had to stop the nurses from pumping me full of IV dramamine just in case it turned out I would need neurosurgery!), to evaluate whether the doctors are in- or out-of-network, and so on.

(We ended up paying $2,400 out of pocket for our daughter's ER visit, including $2.50 for a generic tylenol, despite having gold-plated insurance from Cigna)





Kliff's work reveals the whole story of "market based medicine" to be a fiction. Markets are regulated zones where consumers compare the offerings of producers and make purchase choices based on their information. To call being wheeled unconscious into an ER and raced into an operating theater and then presented with a bill months later a "market transaction" is to make a terribly, grisly joke.





It's as good an argument for Medicare for All and single-payer health care as you could ask for.

Most patients who have successfully negotiated down a bill tell me it wasn't easy. Erin Floyd from Florida told me about her experience reducing two of her daughter's bills — one by 90 percent and one by 45 percent — through a combination of financial aid and prompt care discounts.



On the one hand, she was happy to have the bills lowered. In total, she ended up saving $4,369. On the other hand, the whole process was exhausting. There were lots of phone calls and faxes involved. "I spent at least three hours on the phone working on this," she says. "I was scanning, faxing, emailing, all while I was at work." Over email, she described it as an "incredibly stressful and long process." And then there are, as Slate has noted, patients who have had their bills reversed after journalists wrote about them. Our project, for example, has resulted in $45,107 in medical bills being reversed after Vox began inquiring about those charges. But for all of investigative journalism's merits, reporters writing about medical bills isn't a great solution for the health care system's woes.



I read 1,182 emergency room bills this year. Here's what I learned. [Sarah Kliff/Vox]

(via Naked Capitalism)