Update: After this story was published on June 28, Zuckerberg San Francisco General Hospital agreed to waive the $15,666 trauma response fee charged for Park Jeong-whan’s visit to the hospital. In a letter, the hospital’s patient experience manager said the hospital did a clinical review and offered “a sincere apology for any distress the family experienced over this bill.” Further, the hospital manager wrote that the case “offered us an opportunity to review our system and consider changes.”

On the first morning of Jang Yeo-im’s vacation to San Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in the family’s hotel room and hit his head.

There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital.

The doctors at the hospital quickly determined that baby Jeong-whan was fine — just a little bruising on his nose and forehead. He took a short nap in his mother’s arms, drank some infant formula, and was discharged a few hours later with a clean bill of health. The family continued their vacation, and the incident was quickly forgotten.

Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” which sometimes is known as “a trauma response fee.”

“It’s a huge amount of money for my family,” said Jang, whose family had travel insurance that would cover only $5,000. “If my baby got special treatment, okay. That would be okay. But he didn’t. So why should I have to pay the bill? They did nothing for my son.”

American hospital bills today are littered with multiplying fees, many of which don’t even exist in other countries: fees for blood draws, fees for checking the blood oxygen level with a skin probe, fees for putting on a cast, minute-by-minute fees for lying in the recovery room.  

But perhaps the kingpins are the “trauma fees,” in part because they often run more than $10,000 and in part because they seem to be applied so arbitrarily.

A trauma fee is the price a trauma center charges when it activates and assembles a team of medical professionals that can meet a patient with potentially serious injuries in the ER. It is billed on top of the hospital’s emergency room physician charge and procedures, equipment, and facility fees.  

Emergency room bills collected by Vox and Kaiser Health News show that trauma fees are expensive — typically thousands of dollars — and vary widely from one hospital to another.

In the past six months, Vox has collected more than 1,400 emergency room bills submitted by readers in all 50 states and Washington, DC, as part of an investigation into emergency room billing practices.

The dominant storyline to emerge is what anyone who has visited an emergency room might expect: Treatment is expensive. Fees have risen sharply in the past decade. And when health insurance plans don’t pay, patients are left with burdensome bills.

Charges ranged from $1,112.00 at a hospital in Missouri to $50,659.00 at a hospital in California, according to Medliminal, a company that helps insurers and employers around the country identify medical billing errors.

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“It’s like the Wild West. Any trauma center can decide what their activation fee is,” says Renee Hsia, director of health policy studies in the emergency medicine department at the University of California, San Francisco.

Hsia is also an emergency medicine doctor at Zuckerberg San Francisco General Hospital, but was not involved in the care of the patients discussed in the story — and spoke about the fees generally.

Comprehensive data from the Health Care Cost Institute shows that the average price that health insurers paid hospitals for trauma response (which is often lower than what the hospital charges) was $3,968 in 2016. But hospitals in the lowest 10 percent of prices received an average of $725 — while hospitals in the most expensive 10 percent were paid $13,525. Data from Amino Health, a health cost transparency company, shows the same trend. On average, Medicare pays just $957.50 for the fee.

According to Medicare guidelines, the fee can only be charged when the patient receives at least 30 minutes of critical care provided by a trauma team — but hospitals do not appear to be following that rule when billing non-Medicare patients.

At the turn of the century, such fees didn’t even exist.

But today many insurers willingly pay them, albeit at negotiated rates, for hospitals in their networks. Six insurers and industry groups each declined to discuss the fees, and a spokesperson for America’s Health Insurance Plans, the industry trade group, said, “We have not seen any concerning trends surrounding trauma center fees.”

Trauma centers argue that these fees are necessary to train and maintain a full roster of trauma doctors, from surgeons to anesthesiologists, keeping them on-call and able to respond to medical emergencies at all times.

Zuckerberg San Francisco General Hospital spokesperson Brent Andrew defended the hospital’s fee of over $15,000, even though Jeong-whan didn’t require those services.

“We are the trauma center for a very large, very densely populated area. We deal with so many traumas in this city — car accidents, mass shootings, multiple vehicle collisions,” Andrew said. “It’s expensive to prepare for that.”

Patients face steep bills — and questionable charges — when trauma teams “activate”

Experts who’ve studied trauma fees say that there’s little rationale behind how some hospitals calculate the charge and when the fee is billed. But, of course, those decisions have tremendous financial implications.

After Alexa Sulvetta, a 30-year-old nurse, broke her ankle rock climbing at a San Francisco gym this past January, she faced an out-of-pocket cost of $31,250.

An ambulance brought Sulvetta to San Francisco General Hospital, where, she recalled, “my foot was twisted sideways. I had been given morphine in the ambulance.”

Sulvetta was evaluated by an emergency medicine doctor and sent for emergency surgery. She was discharged the next day.

The hospital charged Sulvetta a $15,666 trauma response fee, a hefty chunk of her $113,336 bill. Her insurance decided that the hospital fees for the one-day stay were too high, and — after negotiations — agreed to pay only a charge it deemed reasonable. The hospital then went after Sulvetta for $31,250.  

“My husband and I were starting to think about buying a house, but we keep putting that off because we might need to use our life savings to pay this bill,” she said.

Andrew, the hospital spokesperson, said that the hospital is justified in pursuing the bill. “It’s fairly typical for us to pursue patients when there are unpaid balances,” he said. “This is not an uncommon thing.”

“I feel like I created a monster”

Trauma response fees were first approved by the National Uniform Billing Committee in January 2002, following a push by a national trauma consulting firm. The high costs of staffing a trauma team available at all hours, the firm argued, threatened to shut down trauma centers across the country.

Trauma centers require special certification to provide emergency care for patients suffering very serious injuries above and beyond a regular emergency department.

“We were keeping an ongoing list of trauma centers that were closing all over the country,” said Connie Potter, who was executive director of the firm that succeeded in getting the fee approved. She now consults with hospital trauma centers on how to bill appropriately.

Trauma teams are activated by medics in the field, who radio the hospital to announce they are arriving with a trauma patient. The physician or nurse who receives the call then decides whether a full or partial trauma team is needed, which results in different fees. Potter says that person can also activate the trauma team based on the consultation with the EMTs.  

But reports from the field are often fragmentary, and there is much discretion in when to alert the trauma team.

An alert means paging a wide range of medical staff to stand at the ready, which may include a trauma surgeon, who may not be in the hospital.  

Potter said if the patient arrives and does not require at least 30 minutes of critical care, the trauma center is supposed to downgrade the fee to a regular emergency room visit and bill at a lower rate, but many do not do so.

Hospitals were supposed to come up with the fee for this service by looking at the actual costs of activating the trauma team, then dividing it over the amount that their patients are likely to pay. Hospitals that see a lot of uninsured and Medicaid patients might charge more to patients with private insurance to make up for possible losses.

But soon, Potter said, some hospitals began abusing the fee by charging an exorbitant amount that seemed to be based on the whims of executives rather than actual costs.

“To a degree, I feel like I created a monster,” Potter said. “Some hospitals are turning this into a cash cow on the backs of patients.”

The $15,666 Sulvetta was charged is San Francisco General’s low-level trauma response fee. The high-level response fee in which the trauma surgeon is called into action is $30,206. The hospital would not provide a breakdown of how these fees are calculated.

Unfortunately, outside of Medicare and state hospitals, regulators have little sway over how much is charged. And at public hospitals such fees may be a way to balance government budgets. At San Francisco General Hospital, the $30,206 higher-level trauma response fee, which increased by about $2,000 last year, was approved by the San Francisco Board of Supervisors.

An ibuprofen, two medical staples — and a $26,998 bill

Some patients question whether their particular cases ought to include a trauma fee at all — and experts think they’re right to do so.

Sam Hausen, 28, was charged a $22,550 trauma response fee for his visit to Queen of the Valley Medical Center in Napa, California, last January.

An ambulance brought him to the Level 3 trauma center after a minor motorcycle accident, when he took a turn too quickly and fell from his bike. Records show that he was alert with normal vital signs during the four-mile ambulance ride, and that the ambulance staff alerted the hospital that the incoming patient had traumatic injuries.

He was at the hospital for only about half an hour for a minor cut on his head, and he didn’t even need X-rays, CAT scans, or a blood test. “The only things I got were ibuprofen, two staples, and a saline injection. Those were the only services rendered. I was conscious and lucid for the whole thing,” said Hausen.

But because the ambulance medics called for a trauma team, the total for the visit came to $26,998 — and the vast majority of that was the $22,550 trauma response fee.

Queen of the Valley Medical Center defended the charge. “Trauma team activation does not mean every patient will consult with and/or be cared for by a trauma surgeon,” spokesperson Vanessa deGier said in an email. “The activation engages a team of medical professionals. Which professional assesses and cares for a trauma patient depends on the needs and injury/illness of the patient.”

Guidelines for trauma activation are written broadly on purpose to make sure they don’t miss any emergencies that could otherwise kill patients, said Daniel Margulies, a trauma surgeon at Cedars-Sinai in Los Angeles and chair of the American College of Surgeons committee on trauma center verification and review. Internal injuries, for example, can be difficult to diagnose at the scene of an accident.

“If you had someone who needed a trauma team and didn’t get called, they could die,” he said. 

Medics err on the side of caution when calling in trauma patients to avoid missing a true emergency. To that end, the American College of Surgeons says it is acceptable to “overtriage,” summoning the trauma team for the 25-35 percent of patients who don’t end up needing it.  

But that logic leaves patients like Jang, Sulvetta, and Hausen with tens of thousands in potential debt for care they didn’t ask for or need, care that is ordered out of an abundance of caution — a call by an ambulance worker, a triage nurse, or a physician — based on scant information received over the phone.

Jeong-whan had fallen three feet from a hotel bed onto a carpeted floor when his nervous parents summoned an ambulance. By the time the EMTs arrived, Jeong-whan was “crawling on the bed, not appearing to be in any distress,” according to the ambulance records. The EMTs called San Francisco General Hospital and, after a consultation with a physician, transported Jeong-whan as a trauma patient, likely because of the baby’s young age.

At the hospital, Jeong-whan was evaluated briefly by a triage nurse and sent to an emergency department resuscitation bay.

Jang recalls being greeted by nine or 10 providers at the hospital, but the baby’s medical records from the visit do not mention a trauma team being present, according to Teresa Brown of Medliminal, who reviewed the case.

The baby appeared to have no signs of major injury, and no critical care was required. Five minutes later, the family was transferred to an exam room for observation before being released a few hours later. Brown says she would dispute the $15,666 trauma response fee because the family does not appear to have received 30 minutes of critical care from a trauma team.

Jang currently has a patient advocate working on her behalf to try to negotiate the bill with the hospital. She fears that the pending medical debt could prevent her from getting a visa to visit New York and Chicago, which she hopes to do in the next few years.  

She said her experience with the US health care system and its fees has been shocking. “I like the USA. There are many things to see when traveling,” she said. “But the health care system in USA was very bad.” 

This story was produced in collaboration with Kaiser Health News.

Help us report on the costs to visit the emergency room. Share your bill here.

It was November 2014, and I was working on a feature story about a buzzed-about blood-testing company in Silicon Valley that promised to “disrupt” the lab industry with new technology. The company, Theranos, claimed its revolutionary finger-prick test would be a cheap and less painful way to screen for hundreds of diseases with just a few drops of blood.

Old-fashioned venous blood draws, where the patient watches as vial after vial of blood is collected, would quickly become obsolete, Theranos promised.

The interviews took a month to arrange. The public relations officer wanted to know, did I “plan on sourcing other people?” and implied that CEO Elizabeth Holmes might not be available to me if I did talk to other sources. I rejected that condition, but finally the company’s public relations contacts agreed to let me visit its site at the Walgreens in Palo Alto, California — one of the first such setups in the country — followed by a sit-down interview with Holmes at her office.

I arrived at the Walgreens on the morning of November 4 and was met by two Theranos press representatives who would supervise my visit. I took out my recording equipment (the story was for NPR) and began approaching patients who were waiting in line to check in for testing.

Some didn’t want to talk to a reporter, but others were open and gracious, sharing with me the reasons they had decided to give Theranos a try. One couple offered to let me come with them into the small testing room, set up to feel like a relaxing spa.

Where were the famous finger-prick blood draws?

A pattern quickly emerged — none of the patients I talked to that day could get a finger-prick test, as promised. Instead, they received a regular venous blood draw, the same as I’d received on numerous occasions at my doctor’s office, though the phlebotomist said the needle was slightly smaller.

I asked the phlebotomist: Was this standard? Did most patients get the venous draw? She told me they “did more finger sticks than venous draws,” but couldn’t give me a number. One of the PR people approached me — I was not authorized to talk to the phlebotomist, he said — and asked me to erase the audio I had recorded. I declined.

I asked him: Why were none of the patients getting a finger prick? Just bad luck and timing, he said. This wasn’t how it usually was, he promised. And wouldn’t I just rather get a finger prick myself and report on the experience, as so many other journalists had agreed to do?

I said no. I needed an actual patient to make a compelling radio story. So I continued waiting for other patients.

Soon, the two Theranos representatives approached me again — with a third on the phone, who said she wanted to talk to me. They were getting complaints about my asking patients questions, she told me. The main Theranos office had gotten several calls from people who had been in the Walgreens that morning, she claimed, complaining that a reporter was bothering them.

I hadn’t pressured anyone. The patients I’d interviewed had all been perfectly friendly and willing. I’ve also been a health reporter for 10 years and never have I been told I was pushing patients to do something that made them uncomfortable.

Something seemed very wrong.

Soon, one of the Theranos representatives approached me again, clearly nervous. They appeared worried. Unless I found a patient getting a finger prick, he said, they would likely have to cancel my interview with Holmes.

It was clearly a threat to try to steer me away from where the story was taking me: Theranos seemed to be doing very few, if any, of its revolutionary tests on actual patients. I asked the press representatives to get the other one on the phone again; I didn’t like being threatened, and I wanted to hash it out with her.

I kept pursuing the story; then something very strange happened

Meanwhile, I sat down with another couple, who had driven 45 minutes to experience the vaunted finger prick. Would they too be steered to a traditional blood test?

As I was interviewing them — but before we knew which test they could get — a sudden and jolting BEEP BEEP BEEP reverberated through the drugstore. “Fire alarm!” someone called out, and we evacuated to the street.

I’d never been in a drugstore when the fire alarm went off. There was no smoke and no fire.

I decided to cancel the feature. I had pitched it as a consumer-focused story about how often “less is more” in health care. I clearly no longer had that story. I made a few more calls to various experts on lab testing to try to figure out what was happening: Was Theranos for real? I was given an interview with a lawyer at Theranos, who promised me that “significantly more than 50 percent of the tests are done with a finger prick,” though she would say no more.

Now that Theranos has been implicated in massive fraud, that encounter serves as a reminder of the skepticism both journalists and health care consumers need to have in an age when public relations, marketing, and advertising try to guide the story and our treatment.

Theranos generated huge hype and laudatory coverage in places like the New Yorker, Wired, and Fortune by selling a compelling idea, even as its PR people couldn’t show me an actual patient who had benefited. Sometimes, in health care, an idea that seems too good to be true, isn’t. We all — patients and journalists — have to do our due diligence.

The PR tactics Theranos employed blocked journalists from providing the kind of scrutiny that might have revealed the fantasy the company was weaving for investors sooner.

And 11 months after my experience at that Walgreens, John Carreyrou of the Wall Street Journal published the first of his groundbreaking investigations surrounding Theranos, blowing the lid off the company’s fraudulent claims. Of the 240 types of blood tests the company said it did, only 15 used finger pricks.

Now comes the news that Theranos has accepted a settlement in the fraud case with the Securities and Exchange Commission. Which has me thinking.

Had someone pulled the fire alarm? I’ve been suspicious since the moment it happened.

Last week, I wrote to Theranos to ask. No surprise: No response.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Jenny Gold is a reporter for Kaiser Health News. Find her on Twitter @JennyAGold.

First Person is Vox’s home for compelling, provocative narrative essays. Do you have a story to share? Read our submission guidelines, and pitch us at firstperson@vox.com.