It started with a Band-Aid. A $629 Band-Aid.
A medical bill emailed to Vox senior policy correspondent Sarah Kliff got her interested in emergency room facility fees—a widely applied, highly variable, and little understood cost in the healthcare system. The fees, set between hospitals and insurers, are the charge from the hospital for coming in for treatment.
Last October, Kliff set out to learn more about these fees through one of the only ways she could think of to get the information: by collecting hospital bills.
By putting out calls on social media and on the site, Vox amassed a collection of emergency room bills. Kliff worked with Senior Engagement Manager Lauren Katz, News App Developer Kavya Sukumar, Visuals Editor Kainaz Amaria and Special Projects Editor Susannah Locke to get the project off the ground. Today, the database comprises more than 1,600 bills from every state and Washington, DC. So far, Kliff has written half a dozen articles from the database, and she’ll continue the to report from the trove through the end of the year. Since Kliff started the project, lawmakers have introduced multiple bills to address surprise medical fees, including legislation sponsored by New Hampshire democratic Senator Maggie Hassan that aides told CJR is inspired by Kliff’s reporting.
CJR spoke with Kliff about how she came up with this approach to researching murky healthcare pricing, what her reporting has accomplished, and what other journalists can learn from her experience. This conversation has been edited for length and clarity.
How long have you been covering healthcare and how did you get interested in this beat?
I started covering healthcare almost a decade ago. I first started with the Affordable Care Act. I was in an entry level position at Newsweek, [where I covered] the consumer health department, and then was on politics. They needed someone to write about the healthcare fight that was happening in Congress. I raised my hand for it, and that’s what I’ve been doing ever since.
Why did you decide to start focusing on emergency department fees?
This whole project actually started with a bill that a reader sent to me. This guy in Connecticut had taken his daughter to the emergency room. It was a 1-year-old girl and he’d been clipping her fingernails and had cut her finger, and it was gushing blood. He was really worried, and it was a weekend, so the urgent care was closed. So he took her to the emergency room. And they said it was nothing to worry about, they put a Band-Aid on her finger and sent them home. And then he received a bill for $629.
I get a handful of medical bills every year, but this one just kind of jumped out at me. That was the start of going down the rabbit hole with emergency rooms. I found out in that bill that the majority of the bill was the facility fee, which is the price of going into the emergency room and seeking service, and that those fees are typically private. You don’t know what they are until you get billed, and they vary hugely from emergency room to emergency room. That story happened in May 2016, and I kept it in the back of my head. Wouldn’t it be cool, I thought, if we could better understand this interaction that happens millions of times a year where people are constantly getting surprise bills?
Could you tell me a little bit about why you decided to crowdsource?
The only way to get emergency room prices is from individual bills. It’s a super frustrating area of the healthcare space for me. Hospitals won’t release this information, insurers won’t release this information.
There are databases that can tell you about prices in a certain state or prices in a certain city, but if you want to see what hospital X charges if you have Y insurance, the only way to get that is to find someone who was sent bills by that hospital with that insurance.
How did you go about putting out this call?
The folks in our social media team were really crucial to this. Particularly Lauren Katz, who has worked on some other crowdsourcing projects for us, helped me figure out how to promote this on our social media channels.
I think one of the really important things we did is on all of my stories having a little callout box. We found that our biggest bumps in submissions would be whenever I wrote a story about emergency room bills. I’d write a story and then a bunch of new bills would come in.
And you built a tool on the site, right, for people to submit?
We had to build that totally from scratch. That was probably the most challenging part of the project because we had to build a secure platform where we’d feel comfortable housing private healthcare data. We had to work pretty closely with our legal team to make sure that the way we were collecting this wasn’t going to put anyone at risk.
When people submit their bills to Vox, we have the permission to read them. I’d love to open the database to other local reporters, because there’s 1,600 bills in here and I’m not going to be able to write about all of them. But we haven’t quite figured out how to manage some of the privacy concerns, and we are very concerned with making sure people don’t feel like they gave us a piece of personal healthcare data and we just share it willy nilly with someone else.
Once you had all these bills in hand, how did you go about digesting the material? Was there a clear story out of it?
I’d say usually every few days I spend an hour or two just reading through the new submissions. It’s basically just me reading them.
One of the themes I saw was a lot of people really struggling financially. I see a lot of folks who are running into one of two situations: Either they have a high deductible, so they’re on the hook for a big chunk of their bill, or they ended up with some kind of out of network charge.
There’s also a huge amount of price variation for very similar services. A story I worked on that really came out of this database—I wouldn’t have found any other way—was about the price of rabies vaccinations. If you are bitten by a raccoon, you can’t really decide not to get the rabies vaccine. It’s literally a life-or-death situation. But the price is incredibly high. We had a bill from someone who had gotten a rabies vaccine at an emergency room, and I think it was about $14,000, and they were on the hook for a good chunk of that because of the set-up of their insurance plan. I searched the database and realized there were other rabies bills, and that they were also in the thousands of dollars, but, like, a big range.
Many of the stories you’ve written are remarkably personal. Were people open and willing to discuss their situations with you?
Yeah. That’s one of the things that surprised me: the number of bills we’ve gotten and the number of interviews I’ve done. People are really enthusiastic. A lot of them are just so frustrated and [feel] like they have no recourse. They’re having their bills sent to collection, and they just feel really helpless in this difficult situation. You know, it can be a surprise how high these fees are. I’ve found that people are actually really excited to have someone take an interest in their case.
You asked readers to share their bills to help change hospitals’ practices of keeping ER fees secret. Has this story made an impact?
We’ve seen a lot of the bills we write about reversed. That being said, I don’t think it’s a great way to run a healthcare system. That’s not a very good systemic reform.
I’m most encouraged by the multiple bills we’ve seen in the Senate introduced to end surprise emergency room billing for the first time in years. It’s notable that both Republicans and Democrats are working on this issue—that, in a very polarized time of healthcare, it’s something everyone can agree this is a really bad situation for patients. (I also give a lot of credit to the folks at Kaiser Health News who are running a really great bill-of-the-month project that has similar features to ours.)
Are there other aspects of the healthcare system that lack transparency that you’d like to investigate after taking on this project?
Oh my gosh, I mean, so many. The whole system is really not transparent. I need to get a 3D dental X-ray, and I can’t even figure out how to find out what the prices are in Washington, DC in an efficient way.
There’s something smart I saw in a newsletter Axios puts out from [lobbyist and former Senate Republican health policy aide] Rodney Whitlock. He was saying these stories about emergency bills and [legislation] around emergency billing are a gateway drug to the rest of the healthcare system. The ER bills are so salient and impactful because they’re so big and because emergency room visits are so common.
If journalists are focusing on this particular area, then it’s an area that’s also getting more attention from you know the policymakers who have the power to do something about it.
What advice do you have for other journalists trying to report on healthcare prices?
Always get the bills. If you’re going to go to a hospital and ask about something that happened there, you need to have the documents: You don’t just need the hospital bill, you also need to know what documents did they get from insurance to figure out what did this person end up on the hook for.
You don’t need a big fancy database or a national outlet. You can use Twitter, you can use Facebook, you can use your media outlet’s account to get information like this without building a tool like the one we built.
You had a personal emergency room experience during the course of your reporting. Do you think that informed your approach to this subject?
Yeah, I think it really did. The emergency room doctor was saying I needed this ultrasound and I didn’t know if the radiologist is in network, but honestly I didn’t bother asking because I was just like, well, I’m not really in a place to protest. I’m pretty sick, I have, like, a 104 degree fever. Luckily the radiologist was in network, so I didn’t end up with any sort of big bill. Our healthcare system asks a lot of patients who are in really vulnerable situations.