On the first morning of Jang Yeo Im's vacation to San Francisco in 2016, her 8-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 (SFGH).
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 a visit lasting three hours and 22 minutes, the bulk of which was for a mysterious fee for $15,666 labeled "trauma activation," also 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, OK. That would be OK. But he didn't. So why should I have to pay the bill? They did nothing for my son."
American hospital bills are today 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 pinnacle is the "trauma fee," in part because it often runs more than $10,000 and in part because it seems 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 and vary widely from one hospital to another.
Charges ranged from $1,112 at a hospital in Missouri to $50,659 at a hospital in California, according to Medliminal, a company that helps insurers and employers around the country identify medical billing errors.
"It's like the Wild West. Any trauma center can decide what their activation fee is," says Dr. 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, 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 be charged only 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 declined to discuss the fees, and a spokeswoman 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, on-call and able to respond to medical emergencies at all times.
SFGH spokesman Brent Andrew defended the hospital's fee of over $15,000 even though the baby 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," said Andrew. "It's expensive to prepare for that."
