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Why Is Room Service So Expensive?

Why Is Room Service So Expensive?


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And how to keep the cost down

Additional charges and fees make dining in your hotel room costly.

After a long day of exploring a city or running to meetings during a business trip, having a hot meal brought up to your hotel room might be the dream for most hotel guests. But with the generally high room service prices, it might be worth thinking twice before placing that order for a club sandwich. After comparing the room service prices in different cities, we at The Daily Meal wanted to know more about what it really is that makes room service so expensive. Clearly, a delivery fee is understandable, as is the usual tipping policy, but what is it that makes the price of a simple club sandwich rise to more than $20?

According to Bill McGee, columnist for USA Today Travel, a major reason why room service gets so costly is because of all the separate additional fees included on the bill. The service charge and delivery fee, as well as taxes, might add up to a whole lot of extra dollars in addition to the item ordered. On top of this, most people would also tip the server, as they're not aware that the tip is actually included in the "service charge." And here it becomes tricky: a "service charge" includes tip, but a "delivery charge" or "room service charge" does not, McGee points out. He recommends to always double-check with the hotel or server in order to be clear on the pricing, and hopefully save a few dollars. "Industry analysts note that hotels are just like other travel suppliers, eager to increase revenues through add-on services," McGee writes. In other words, as long as hotel guests are continuing to order room service, the prices will stay high. And with tired tourists and people looking for a way to relax, the allure of ordering room service persists. Rebecca Kawano, spokesperson for Carlson Hotels, says that about 35 percent of their guests order room service, and representatives for InterContinental and Wyndham hotels also say that most of their guests order food to their rooms.


Why An ER Visit Can Cost So Much — Even For Those With Health Insurance

Vox reporter Sarah Kliff spent over a year reading thousands of ER bills and investigating the reasons behind the costs, including hidden fees, overpriced supplies and out-of-network doctors.

This is FRESH AIR. I'm Terry Gross. You wouldn't believe what some emergency rooms charge, or maybe you would because you've gotten bills. For example, one hospital charged $76 for Bacitracin antibacterial ointment. One woman who fell and cut her ear and was given an ice pack but no other treatment was billed $5,751. My guest, Sarah Kliff, is a health policy journalist at vox.com who spent over a year investigating why ER bills are so high even with health insurance and why the charges vary so widely from one hospital to the next.

Through crowdsourcing, she collected over a thousand ER bills from around the country. She interviewed many of the patients and the people behind the billing. She's reported her findings in a series of articles on Vox. She's also spent years reporting on the battle over health insurance policy. We'll get some updates on the state of Obamacare a little later in the interview.

Sarah Kliff, welcome back to FRESH AIR. Why did you want to do an investigation into emergency room billing?

SARAH KLIFF: You know, I wanted to do this because the emergency room is such a common place where Americans interact with the health care system. There are about 140 million ER visits each year. It's a place where you can't really shop for health care. You can't make a lot of decisions about where you want to go. So I think that is big-picture what got me interested.

Small picture was actually a bill that someone sent me almost three years ago now, where they took their daughter to the emergency room. A Band-Aid was put on the daughter's finger, and they left. And they got a $629 bill. And they said - you know, they - the parents sent this to me, saying, how could a Band-Aid cost $629? And I said, I don't know, but I'm going to find out. And that kind of opened up the door to this, you know, multi-year project I've been working on right now. It started with trying to figure out why a Band-Aid would cost $629.

GROSS: OK. So let's get to that $629 for treatment that was basically a Band-Aid placed on a finger. You investigated that bill.

GROSS: Why'd it cost so much?

KLIFF: So what cost so much was really the facility fee. So this is a charge I hadn't heard about before as a health care reporter. This is a charge that hospitals make for just keeping their doors open, keeping the lights on, the cost of running an emergency room 24/7. So if you look at that particular patient's bill, the Band-Aid - you know, I hesitate to say only - but the Band-Aid only cost $7, which, as anyone who's bought Band-Aids knows, is quite expensive for a single Band-Aid.

But the other $622 of that bill were the hospital's facility fees for just walking in the door and seeking service. And these fees are not made public. They vary wildly from one hospital to another. And usually patients only find out what the facility fee of their hospital is when they receive the bill afterwards, like that patient, you know, that sent me this particular bill.

GROSS: And does the facility fee vary from facility to facility?

KLIFF: It does significantly. You know, I've seen some that are in the low hundreds. I've seen some that are in the high thousands. And it's impossible to know what facility fee you're going to be charged until you actually get the billing documents from your hospital. And if you try and call up a hospital and ask what the facility fee is, usually you won't get very far.

So it's this fee that, from all the ER bills I've read, is usually the biggest line item on the bill. But it's also one that is very, very difficult to get good information about until you've already been charged.

GROSS: So you're paying the facility fee to basically share in the cost of running the emergency room.

KLIFF: Yes, that's how hospital executives would describe the fee.

GROSS: But you don't know that when you're going to the emergency room.

KLIFF: You don't, no. And you don't know how much it'll be. You don't know how it's being split up between different patients. You don't know any of that.

GROSS: So is this also why one bill had $60 for the treatment of ibuprofen and another $238 for the treatment of eyedrops?

KLIFF: Yeah. And, you know, this is something I see all the time reading emergency bills - I've read about 1,500 of them at this point - is that things you could buy in a drugstore often cost significantly more in the emergency room. And the people I talked to who run hospitals will say this is because they have to be open all the time. They have to have so many supplies ready.

But I think one of the things that I find pretty frustrating is, you know, patients aren't usually told, we can give you an ibuprofen here, or you can pick some up at the drugstore if you leave, and the cost will be a fraction of what we would charge you here. That information often isn't conveyed to patients who are well enough, you know, to go to a drugstore on their own. But it's just huge variation for these simple items.

One place I see this a lot is pregnancy tests. If you're a woman who's of childbearing age, you go to the emergency room, they will often want to check if you're pregnant. I've seen pregnancy tests that cost a few dollars in emergency room. The most expensive one I saw was over $400. I believe that was at a hospital in Texas. It's just widespread variation for, you know, some pretty simple pieces of medical equipment.

GROSS: I want to get back to the $60 ibuprofen. Is that - does that include the facility fee? Or is that just for the ibuprofen, and the facility fee is separate?

KLIFF: That's just for the ibuprofen. The facility fee is totally separate.

GROSS: So how do they justify that?

KLIFF: They say they have to stock, like, a wide array of medicine, so they have to have everything on hand from ibuprofen, from, you know, expensive rabies treatments - I've talked to a lot of people who've been to the emergency room for exposure to bats and raccoons - and that they need to have all these things in stock. And, you know, one of the things you pay for at the emergency room is the ability to get any medication at any hour of the day right when you need it. I don't necessarily buy that explanation, to be clear. That's what I've heard from hospital executives.

I think it's pretty telling that ibuprofen has a very, very different price depending on which emergency room you go to. The fact that there's so much widespread price variation suggests to me that it's not just the cost of doing business driving it, that there's also business decisions being made behind ibuprofen that are driving the prices different hospitals are setting.

GROSS: Now, of course, trips to the emergency room aren't always as simple as getting a Band-Aid or ibuprofen or some eyedrops. I want you to describe the case of a young man who was hit by a pole on a city bus in San Francisco.

KLIFF: Yeah. So this patient, his name is Justin. He was a community college student in northern California, was walking down a sidewalk in downtown San Francisco one day. And there was a pole hanging off the back of the bus that wasn't where it's supposed to be. It essentially flew off the back of the bus, hit him in the face and knocked him unconscious.

And the next thing he knows, he's waking up at Zuckerberg San Francisco General, which is the only Level I trauma center in the city. He ends up needing a CT scan to check out some brain injuries. He needs some stitches. And then he's discharged. He ends up with a bill for $27,000.

But, you know, as I began figuring out through my reporting, San Francisco General does not contract with private insurance, and they end up pursuing him for the vast majority of that bill. He has $27,000 outstanding. And somewhat ironically, San Francisco General, it is the city hospital. It is run by the city of San Francisco. So this student is hit by a city bus, taken by an ambulance to the city hospital and ends up with a $27,000 bill as a result.

GROSS: So did he have insurance?

KLIFF: He did. He had insurance through his dad.

GROSS: So why doesn't Zuckerberg San Francisco General Hospital contract with private insurers?

KLIFF: So what they have told me when I've talked to some spokespeople there is that they are a safety net hospital, and that is, you know, definitely true. They generally serve a lower-income, often indigent population in San Francisco that would have trouble getting admitted and seeking care at other hospitals in the city. So they have told me that their focus is on serving those patients and that therefore, you know, they're not going to contract with private insurance companies.

The thing I found a little bit confusing about that, though, is there are lots of public hospitals, say, that, you know, also serve low-income populations. And some of them for their inpatient units, you know, for their scheduled surgeries, they're not going to contract with private insurance because they want to make sure beds are available for the publicly insured folks and people on Medicaid and Medicare.

But when it comes to the emergency room, you know, every other public hospital I was in touch with would contract with private insurers there because people don't decide if they're going to end up in the emergency room. So, you know, that's the justification they offered, that it is a hospital meant to serve those with public insurance. But it is not something you see public hospitals typically doing.

GROSS: Isn't - I think legislation was proposed in California to change that. Did that pass?

KLIFF: It's still pending in the California State Assembly. And the hospital has also promised to reform its billing practices, although we haven't seen what exactly their new plan is yet.

GROSS: So the position that Justin was in is that, like, he's unconscious. He's not asking to be taken anyplace. (Laughter) But he's unconscious. He's taken to the emergency room and ends up getting this $27,000 bill. I mean, that just seems so unfair, especially since he has insurance.

GROSS: Like, it's supposed to cover him for things like that (laughter).

KLIFF: Yeah. You know, there's one other patient who kind of makes this point really well who was also seen at San Francisco General. Her name is Nelly. And she fell off a climbing wall and, somewhat amazingly, you know, turns out she had a concussion. But one of the first things she does is she calls her insurance's nursing hotline to ask, should I go to the ER?

And they say yes. And she says, can I go to Zuckerberg San Francisco General? It's the closest. They say, no, don't go there. It's not in network. Go to another hospital. She gets to the other hospital, but the other hospital won't see her because she's a trauma patient. She fell from a really high height. And San Francisco General is the only trauma center in San Francisco. So she tries to go to an in-network hospital. She's then ambulance-transferred to Zuckerberg San Francisco General, and she ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.

But I think it's just such a frustrating situation for someone like Justin, for someone like Nellie (ph). They're either shopping for this good unconscious, they're really trying to do the right thing, and the health care system is just so stacked against the patient. It's so stacked for the hospital to be able to bill the prices that they want to bill.

GROSS: So apparently, the moral of the story is if you want to challenge your emergency room bill, you should get Sarah Kliff to write about you. (Laughter).

KLIFF: It's - (laughter). That's what some people have said. But there's only one of me, and there's about 2,000 bills in our database. And, you know, we have had over $100,000 in bills reversed as a result of our series. But I don't think it's a great way to run a health care system where we just, you know, the people who get their bills reversed are those who are lucky enough to have a reporter write a story about them.

GROSS: Yes. Agreed. Let me reintroduce you. If you're just joining us, my guest is Sarah Kliff. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy actually affects people.

So we're going to take a short break, and then we'll talk more about emergency billing. And then later, we'll talk about what's left of Obamacare, and what the president and Congress and candidates are saying about health care, after this break. This is FRESH AIR.

(SOUNDBITE OF ALEXANDRE DESPLAT'S "SPY MEETING")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff. We're talking about emergency room billing and why it's so unpredictable and often so incredibly high. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy affects people.

So we were talking about the hidden facility fee, which most people don't know exists, and is responsible for a large chunk of a lot of emergency room bills. There's also, like, a trauma unit fee. It's a similar hidden fee in hospitals that have trauma centers in their emergency rooms. So explain the trauma fee and how that kicks in.

KLIFF: Yeah. This is something I also had never heard of till I started reading a lot of emergency room bills, and this is the fee that trauma centers charge for essentially assembling a trauma team to meet you when you're coming in and those folks out in the field, maybe the EMTs, for example, have determined that you meet certain trauma criteria.

So I've talked to people who have been charged trauma fees who were in serious car accidents. One case was a baby who fell from more than 3 feet, and that's considered to trigger a trauma activation. So this is essentially the price for having a robust trauma team - a surgeon, an anesthesiologist, nurses - all at the ready to receive you when you get to the hospital.

And again, these fees can be pretty hefty. San Francisco General, which, I've done the most reporting on their billing, you know, they can charge up to $18,000 for their trauma activation services. I wrote about one family who was visiting San Francisco from Korea when their young son rolled out of the hotel bed. They were nervous. They didn't know the American health care system well. So they called 911, which sent an ambulance, brought him over to the hospital. Turns out, he was fine. They gave him a bottle of formula. He took a nap and went home.

And then a few months later, they get an $18,000 charge for the trauma team that assembled for when that baby came to the hospital. And these are another, you know, pretty significant fee that, again, you don't really know about. You have no idea that the trauma team is assembling to meet you when you're coming into the hospital. You just find out after the fact. And you also have no say in the decision to assemble trauma. That's really left up to the hospital, not the patient.

GROSS: So I'm going to have you compare two possibilities. You go to an emergency room, and the bill is very high. There's two people who have the same problem who go to the emergency room. One of them has a copay. One of them has a high deductible that they haven't paid off yet. How are they treated differently, in terms of what they're billed for the emergency room visit?

KLIFF: Well, the person with the deductible will likely be billed significantly more. You know, if they're just, let's say, at the start of the year, they are going to essentially have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and, you know, probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well.

KLIFF: So one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one.

GROSS: That seems so unfair. How are you to know - if you're choosing a hospital that's in network, how are you to know whether the doctor treating you is in network or not?

KLIFF: You know, you really - there isn't a great way to tell, to be honest. This is - you know, when I had to go to the emergency room over the summer, you know, this is something I worried about. You know, I was seeing a doctor who worked for the hospital, but they were sending off my ultrasound to be read by a radiologist who I was never going to meet. I couldn't ask them if they were in-network. I just kind of had to cross my fingers and hope for the best, and luckily, I didn't get a surprise bill.

But I've talked to multiple patients who, you know, tried to do their research, who thought they were in network, only to get a bill, often for thousands of dollars, after leaving the emergency room, from someone who, you know, never mentioned to them, hey, I'm not in your network like this hospital is.

GROSS: So the bill that you'd get would be for the difference between what you pay when somebody is - when a doctor's in network and what you pay when they're not in network?

KLIFF: Yeah, often it's just what that out-of-network doctor wants to charge. So a good example of this is a patient I wrote about in Texas named Scott (ph), who was attacked in downtown Austin, left on the street unconscious, some bystander called him an ambulance, and he woke up at a hospital. And one of the first things he does, because this is the United States, is he gets on his phone and tries to figure out which hospital he is at, and, you know, is that in his insurance network? And he finds out - good news - it is. And a surgeon comes by, tells him he's going to need emergency jaw surgery because of the attack that happened.

So he says, OK. You know, he's not really in a place to go anywhere. Gets the surgery. Goes home. A few weeks later, he gets an $8,000 bill from that oral surgeon, who the insurance companies paid a smaller amount. The oral surgeon didn't have a contract with the insurance and said, you know, I think my services are worth a lot more, so pursued the balance of the bill from Scott.

GROSS: I have to say, I mean, that does seem unfair to the patient because they haven't been informed. They can't make a choice about it if they don't know. And, like, $8,000 is a lot of money.

KLIFF: Yeah. And I think, you know, even more, let's say he did say he was out of network. It kind of puts the patient in an unfair situation, too. You know, one of the things we talk about a lot in health policy is, what if we had more transparency? What if we let patients know the prices? What if we let patients know who is in and out of network? And that - it would be a good step.

But, you know, I think with someone like Scott, sitting in a hospital with a broken jaw, there's not much you can do with that information. He doesn't have, you know, the ability to go home, like, research, like, make an appointment with a new surgeon. So, you know, it'd be great if he knew that the doctor was out of network. It'd be even better if he had some kind of protections against those type of bills.

GROSS: What kind of protection could there be?

KLIFF: So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless. When there is a situation like Scott's, for example, where there's this $8,000 bill, that's really a dispute between a health insurance company and a doctor, where the doctor says, I want more money, the insurer says, I want to pay you less money. And what Congress wants to do - what a few states have already done with their laws - is said, you can't go to the patient for that money. You, the hospital, and you, the health insurance company, you have to get down to a table and work things out together.

And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation because, like you said, Terry, they really aren't in a position to negotiate. They aren't in a position to shop. They shouldn't be the ones who are left holding the bag at the end of the day.

GROSS: My guest is Sarah Kliff. She covers health policy for Vox. After a break, we'll talk more about why ER bills can have some unpleasant surprises, and she'll give us an update on Obamacare. And Maureen Corrigan will review two books about forgotten stories from Hollywood. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF JESSICA WILLIAMS TRIO'S "KRISTEN")

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with journalist Sarah Kliff, who covers health policy and how it affects people for Vox. For the past year and a half, she's been writing about why emergency room visits can be so expensive and the pricing so secretive and mysterious, as well as inconsistent from one hospital to the next. She collected over 1,000 bills and tracked down stories behind the billing. She interviewed many of the patients and the people behind the billing to decipher why ER bills can have some surprise costs.

Here's another surprise that often awaits people who go to emergency rooms - some insurance plans only cover true emergencies, and whether it is a true emergency is sometimes determined after the diagnosis is made. So how are you supposed to know before the diagnosis whether you're going to be categorized as a true emergency or not? Like, if you go to the hospital, you don't know if you have a broken bone or not.

GROSS: Somebody needs to X-ray it and tell you.

KLIFF: Right. The whole point you go to the emergency room is to help them figure out what the emergency is and what treatment you need. This is a policy that the insurance company Anthem has been pioneering for a few years. It's been in Kentucky. It's been in Georgia - a few other states. And, you know, I wrote about one patient out in Kentucky named Brittany, who - she was having really severe abdominal pain. She called her mom who is a nurse, and the nurse said, that might be appendicitis. You've got to get to the emergency room. Turns out it wasn't appendicitis. It was an ovarian cyst. She got it treated elsewhere later down the line.

And Anthem, you know, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. This is another one where, once I started asking them about it, the bill suddenly disappeared. But - and it seems like as Anthem has gotten more attention for this policy - they haven't announced it publicly, but some pretty compelling data The New York Times got their hands on suggest they've backed off this policy.

But it's just, you know - there are so many traps you can fall into going into an emergency room. It just feels like you're walking into this minefield, and this is kind of one of those mines that's lurking in there.

GROSS: Hospital pricing and emergency room pricing seems to vary so much from hospital to hospital. Are there, like, national guidelines that help determine what a hospital or a hospital emergency room charges for services? I mean, who decides, and why is there such a variation?

KLIFF: So hospital executives get to decide, and I think that is why there is such variation. There aren't really guidelines that they're following. You know, one thing you could do as a hospital executive - you could look at what Medicare charges - those prices are public - and, you know, maybe use that as a benchmark. There are some databases. There's one called FAIR Health, for example, where you could look and see, you know, some information on what local prices typically are. But in terms of, you know, what you want to charge, that's kind of up to you as someone running a hospital.

One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States. You know, if you're a hospital, you just choose your prices. And, you know, that is, I think, why you see so much variation and why you see some really high prices in American health care.

GROSS: So what advice do you have for people who actually need an emergency room and don't want to get hit with a shocking bill afterwards?

KLIFF: Yeah, this is, you know, one of those questions - it just makes me a little frustrated that - 'cause this is the most common question I get - right? - is, how do I - how do we - how do I prevent a surprise bill? And I find it kind of upsetting that, you know, it has to be on the patient because honestly, there really isn't a great way to do this. I've talked to so many patients who tried so hard to avoid a big medical bill and weren't able to.

You know, there's certain things, yes, you can do. You can look up the network status of your hospital. You can try and badger each doctor you see about whether they are in network. You can try to be a really proactive patient, but I think that's just such a huge burden on people who are in, like, really emergent situations. And some people don't have that opportunity, you know, like Justin Zanders, the guy we were talking about earlier who was taken to a hospital while he was unconscious. I cannot think of anything he could've done to avoid that bill. It just was not possible.

GROSS: So your advice is, good luck.

KLIFF: Short of that, I mean, good luck. You know, I'm actually in the middle of reporting a story right now about people who have successfully negotiated down their bills. And, you know, you can certainly - if you do end up with a surprise bill, you can call up the hospital, see if there's a discount. Sometimes there will be. Sometimes there won't. You can call again. Customer service representatives - different ones - often offer you different discounts, I've learned from interviewing patients. You can ask for a prompt pay discount if you pay right away.

You can - you know, one health attorney who negotiates these a lot on behalf of patients - he says one of his favorite tactics is to choose the amount you want to pay send a check with that amount and in the note, write, paid in full and hope they don't come after you after that. I have no idea if that works or not, but he says it works for his patients. But it's a mixed bag. And at the end of the day, the hospital has all the power. You can ask for discounts. You can ask nicely. You can ask angrily. It's up to the hospital if they want to grant you that or not.

GROSS: So what is the status of Obamacare now? You know, Republicans promised to repeal and replace. That didn't work out. So have Republicans given up on repeal and replace?

KLIFF: For the time, it seems pretty clear that repeal and replace is dead on arrival, especially with Democrats taking control of the House this year. Those proposals aren't being talked about as much. They're not really going anywhere. The one big thing we did see Republicans succeed at is repealing Obamacare's individual mandate, the requirement that all of us carry health insurance. That happened as part of the big tax package that passed at the end of 2017.

So we've seen, you know, President Trump, for example, essentially declare victory, declare that repealing the individual mandate is repealing Obamacare, so we're good on that goal. But, you know, generally, Obamacare is still standing. There are millions of people getting their coverage through the Affordable Care Act still today.

GROSS: So now that there's no individual mandate, conservative attorney generals are challenging Obamacare - the Affordable Care Act - and saying it's no longer constitutional after Congress's repeal of the individual mandate. Could you explain that?

KLIFF: Yeah, so this is a challenge that's come up through the courts in the past few months. Obamacare is constantly being challenged in court. It's been through multiple Supreme Court suits. This one - you know, it's a multiple-part argument, so I'll try my best to walk through it.

KLIFF: So essentially, it starts with the fact that the individual mandate - they weren't quite able to repeal it for boring technical reasons. But what they were able to do is change the fee for not having health insurance from $700 to . So it - in all practical terms, it feels like repealing it because there is no fee for not carrying health insurance. The individual mandate was upheld as a tax when the Supreme Court said, yes, this is constitutional. The government has a right to tax people. Now that there is no fee associated with not carrying health insurance, the conservative attorneys general who are bringing this case argue that it's not a tax anymore, and therefore, it is not constitutional. That whole defense that John Roberts wrote in 2012 is moot. So that's the first part of it.

They go even further and say the individual mandate is so core to the Affordable Care Act, it is not severable. And if you, the courts, rule the individual mandate unconstitutional, then you need to rule all of Obamacare unconstitutional. And the first judge who heard this case - he is a, you know, judge in a district court in Texas. He agreed with them. He agreed that - first step - that the individual mandate is no longer constitutional. And second step, that means that the entirety of Obamacare has to fall. This is now being appealed up to the 5th Circuit Court of Appeals.

And I will say there are a lot of critics of this case. There are a lot of people who were parties to previous Supreme Court challenges to Obamacare who think this is a bad legal argument and that it will not succeed. But it is already, you know, gone through the district court level. It's moving up to the appellate court level. It is something that is in the mix that could become a threat to the Affordable Care Act.

GROSS: Well, if it goes to the Supreme Court, it would be very interesting to see what Justice Roberts says since he voted for the ACA, saying that the individual mandate was a tax.

KLIFF: Yeah. You know, and I think where some legal scholars would see it shaking out is that the - someone like John Roberts, he might agree, OK, yeah, the individual mandate is unconstitutional, but would not make the leap to the second half of this, that the rest of the law has to fall.

I think one of the most compelling arguments against this case is that Congress knew what they were doing when they repealed the individual mandate. You know, they had the opportunity to repeal Obamacare. They didn't. They'd specifically took aim at this one specific part. So it feels like it might be a bit of a reach to argue that what Congress really meant to do was repeal all these other parts of the Affordable Care Act. But, you know, the Supreme Court is changing. We have a new justice. You know, we have a lot in the mix. So it's always an open question of how a decision like this could go.

GROSS: So correct me if I'm wrong here - the Department of Justice has sided with the conservative attorneys general who are challenging Obamacare, saying it's no longer constitutional, and I think that the Justice Department is also asking the judge to strike down the ACA's mandatory coverage of pre-existing conditions.

KLIFF: Yeah, that's right. So it's a kind of unusual situation. Usually, it's the Justice Department that is going to defend a federal law in court. But, you know, given the Trump administration's opposition to the Affordable Care Act, they have decided to side with the conservative attorneys general. They have a slightly different argument. They don't think all of Obamacare should fall if the mandate falls, but they do think some big parts, like you mentioned, the protections for pre-existing conditions, should be ruled unconstitutional if the mandate falls.

So this has led to a bit of an unusual situation where you've had this coalition of Democratic attorneys general step in and take over the case, basically saying that the federal government is going - is not going to defend the Affordable Care Act. We are going to defend the Affordable Care Act. So you have this coalition of Democratic attorneys general, led by the attorney general of California, stepping in and, you know, offering a defense as this case works its way up through the court system.

GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Sarah Kliff. She's senior policy correspondent at Vox, where she focuses on health policy. And she hosts the Vox podcast "The Impact," about how policy actually affects people. We'll be right back. This is FRESH AIR.

(SOUNDBITE OF THE WEE TRIO'S "LOLA")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff, senior policy correspondent at Vox, where she focuses on health policy.

Do you think health insurance is shaping up to be a big issue in the 2020 campaign?

KLIFF: I do, and I think it's going to be a big issue both in the primary, where you're already seeing candidates get pressed on, should we still have private health insurance, and giving pretty different answers to that question.

And then I think one of the things you're also going to see is whoever is the Democratic nominee is probably going to run on Obamacare. They are going to point at the fact that President Trump tried to repeal the Affordable Care Act. That's pretty different than, you know, the 2012 election, where Democrats were pretty scared to run on Obamacare. It still wasn't popular. The benefits hadn't rolled out. In this past midterm and now again in the 2020 election, it seems pretty clear that Democrats are pretty excited to point out that Republicans wanted to repeal Obamacare. So I think it really will come up.

GROSS: What are some of the biggest falsehoods you've heard from politicians about health insurance costs or health insurance policy?

KLIFF: You know, one of the ones that's come up a lot is actually around the role of private health insurance. So I've - I don't know if it counts as a falsehood, but I think it's a bit of a misunderstanding of how health insurance often works is, you know, when I talk to single-payer supporters, most of them want to eliminate private insurance completely. They just don't think there is a role for it in the health care system.

And one of the things I think that's actually pretty interesting, when you look at any other country - you look at Canada, you look at the U.K., you look at France, which all have national health care systems - all of them have a private health insurance market, too. There are always some kind of gap in the system that the public insurance can't cover, where the government step - where the private industry steps in and offers coverage. In Canada, for example, their public health plan doesn't cover prescription drugs, so two-thirds of Canadians take out a private plan, often through their employer, like us, to cover prescription drugs, to cover their eyeglasses, to cover their dental. So I think that's a confusion I see a lot in the "Medicare for All" debate coming up right now.

I think the other thing I see a lot of confusion around - and we've talked about this a little bit with emergency room billing - is the role of transparency in health care. I see a lot of, you know, if we just made the prices public, like, that is what we need to do to fix the system, and I think that really misses the fact that, even if the prices were public, health care is so different from everything else we shop for. It might be - I think it is the only thing we purchase when we are unconscious.

KLIFF: And when you're unconscious, you're not really going to be great at price shopping. So I see that as, you know, a halfway solution that I often hear talked about here in Washington that would be great but is not going to suddenly result in, you know, prices dropping because they've been exposed in a spotlight.

GROSS: Is there a country that you think has a good health care model that we could borrow?

KLIFF: Oh, yeah. I've been thinking about this a lot lately actually. So I've gotten very interested in the Australia health care system, which is a little far away. But I think they're a really interesting model because they have a public system, everyone's enrolled in it, but they also really aggressively try and get people to buy a private plan, too, and that private plan will get you sometimes faster access to doctors, maybe a private room at a hospital.

It's really hard for me to see the U.S. creating a health care system, similar to Canada's actually, where you can't buy private insurance, where if you're rich or you're poor, everyone waits in the exact same queue, you can't jump to the front of the line. Because I think wealthier Americans have gotten so used to having really good access to health care that they would be very upset with a system like that.

I think Australia is a kind of interesting hybrid between, you know, where we're at in the U.S. right now and what Canada is like, where it says, yes, we're going to create a public system for everybody, but we're also going to have these private plans that compete against the public system. So I've become increasingly, you know, interested in how Australia's system works. And they have - about 47 percent of Australians are buying a private plan to cover the same benefits that the public plan does.

GROSS: So it's not supplemental. It's instead of.

KLIFF: Right. So it's very different from Canada. So in Canada, you can buy complementary insurance, you know, to cover the benefits the public plan doesn't but the government expressly outlaws supplemental insurance. You know, like, what people buy here to cover the gaps in Medicare, that is not allowed. You cannot buy your way to the front of the line in Canada.

One of my favorite sayings about the Canadian health care system is from a doctor in a book I read about Canadian health care is they said, you know, we're fine waiting in lines for health care in Canada as long as the rich people and the poor people have to wait in the exact same line. Their system is all about equality. And I just don't know that we're at a place as a country where we value the same sort of equality in our health care system.

GROSS: Is there any developed country around the world that has a system similar to ours with all these competing insurance companies and, you know, some government plans and, like, a thousand different bureaucracies that doctors have to deal with and that patients have to deal with?

KLIFF: Absolutely not. There's nothing like it. I mean, our system is so unique. I'd say the closest but it's not even close are a few countries that have national health care systems, but they do it through tightly regulated private health insurance plans. So if you look at, like, Netherlands or Israel, there isn't a government-run plan. Instead, in both countries, you actually have four tightly regulated health insurance plans that compete against each other for the citizens' business. I guess that's the closest, but that is so different from what we have here right now. There's really nothing like it in any developed country.

GROSS: Sarah Kliff, thank you so much for talking with us.

KLIFF: Well, thank you for having me.

GROSS: Sarah Kliff covers health policy for Vox, where you'll find her series about emergency room bills. After we take a short break, Maureen Corrigan will review two books about forgotten stories from Hollywood. This is FRESH AIR.

(SOUNDBITE OF GEORGE FENTON AND PHILHARMONIC ORCHESTRA'S "MISS SHEPHERD'S WALTZ")

Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

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Why Is Room Service So Ridiculously Expensive?

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Quora.com is a question-and-answer site where content is written and edited by its community of users. Occasionally we syndicate content from the site if we think it will interest TPG readers. This article originally appeared on Quora.com in response to the question, Why Is Room Service So Ridiculously Expensive? and was written by David Trustrum, who has more than 20 years of experience in hotels, restaurants, bars and banqueting.

In my experience, which is in mid-market hotels in the UK, room service is so expensive for several reasons, the most important of which, as far as I am concerned, is to discourage people from having it.

Why do we wish to discourage room service? Because providing room service is a monumental pain in the backside.

  • Management hates room service. If a guest wishes for room service outside normal restaurant hours, that is immediately two extra members of staff we have to pay for, one to cook it and one to serve it. Plus, these staff need to be on standby, and therefore paid, whether there are any orders or not, just in case one should come in. With staff costs what they are, (often 70% of hotel costs) and the fact that room service is nowhere near as common in the UK as it is in the US, this is an expense most hotels here just can&rsquot afford. Room service therefore is often only available during the normal opening hours of the restaurant.
  • Restaurant managers hate room service. Each room service order takes a member of staff off the restaurant floor for at least 15 minutes. As most people tend to eat within the same short time-frame (usually between 6:00pm and 8:00pm) you can often get several room service orders at a time. And each one takes a member of staff away from the restaurant. If the order is for more than one course, it can tie a waiter up for an hour. If it is for more than one person, it can tie up two or three waiters. This can drastically affect the restaurant service. The restaurant is normally short staffed to start with, and you only dare send your most reliable staff off on the trek, as anyone else will grab the opportunity for a break and be gone for hours.
  • Staff hate room service. As this is the UK, they rarely receive a tip for delivering it &mdash gratuity is almost non-existent in the UK, and the room service charge does not go to the member of staff &mdash and when they do it, is only a couple of pounds. This is not worth the long and awkward trek down corridors, with a precariously laden tray, up stairs and through fire doors. And even if you are lucky enough to have a recently built hotel corridor that is nice and level, have you tried to get a trolley through a fire door? It is also inevitable that someone ordering room service will be in the room farthest from the kitchen.
  • Chefs hate room service, as they know that by the time the staff member has transported their meticulously presented creation down said corridors, it will be all over the plate &mdash and probably the tray &mdash and if not stone cold, then certainly not as hot as it should be. Plus, the food hygiene considerations are worrying, at least.
  • Housekeeping hate room service. Left over food smells. Trays block up trolleys and corridors, and what a red wine jus can do to a nice white bedspread is best not considered.

All in all, room service is expensive because we do not want you to have it. And why the hell would you want to eat a cold meal in your little hotel bedroom anyway?


Why Wildly Expensive Room Service Still Loses Hotels Money

Apparently, the New York Hilton Midtown will no longer be offering room service. So customers will no longer have the option of ordering cookies and milk for $20. That’s got to be a lucrative business, right? Maybe not. Check out this report from Marketplace.

This quote from the report gets to the heart of the problem.

“It’s very rare, if not impossible, for hotels to produce revenue in terms of room service,” says Mehmet Erdem, professor at the Harrah College of Hotel Administration at University of Nevada, Las Vegas.

Hotels typically lose money keeping a full kitchen and wait staff on standby. That’s the key reason hospitality watchers believe hotels are killing room service. In many cases, that means job cuts for hotel workers, 55 at the New York Hilton alone. For its part, Hilton says it’s ending room service because of declining demand.

In essence, an in-room dining operation suffers from being a small-scale queuing system that needs to deliver a high service level (and thus is not unrelated to our earlier discussion of Tesla’s charging stations). Queuing system’s benefit from economies of scale so as the arrival rate goes up the total capacity needed to deliver a desired service level increases but that capacity will be more heavily utilized. Going the other way, if the Hilton experienced decreasing demand, it could shed some workers but not enough to get the utilization level back up to what it once was. The cost of providing the service consequently increased. Thus it is not that it costs $20 to get a cookie up to a guest’s room but that it is expensive to have staff spending a lot of time not bringing cookies up to someone’s room. The unscheduled nature of room service further complicates the problem. A restaurant can smooth out the flow of orders by using reservations or strategically delaying moving patrons from the bar to a table. The in-room dining staff has to take the orders as they are called in.

There are a lot of (primarily local) services that face similar issues. Think about a plumbing emergency. If you call a plumber asking for immediate service, you will likely be quoted a very high rate. It is natural to surmise that the price is jacked up because you just told them that you are literally up shit creek, but except in the smallest of towns, plumbing is a competitive business (unlike room service at a particular hotel). One firm would presumably have an incentive to cut its rate a little, dominate the local plumbing emergency market, and probably win a loyal following for mundane, scheduled work. That doesn’t happen — presumably because having skilled tradesmen sitting around underutilized waiting for an emergency call is just too expensive.


Five myths about hotel room service

Important stuff you should know before you ring down to the desk.

There’s nothing quite like hotel room service. Be it an indulgence or a necessity, few things seem better suited to serve a jet-lagged traveler than a freshly delivered breakfast tray or a late-night sandwich. While seasoned road warriors may have their room service routines down to a science, many of us pause before picking up the phone to order. Maybe it’s the fact that room service food can seem incredibly expensive, take forever to get to the room and is often tepid and less than tasty when it finally arrives. Here are five myths about room service.

1. Room service menu prices are identical to those in the hotel’s restaurant.

It sure doesn’t seem that way. John Mariani, the legendary food critic and author of Mariani’s Virtual Gourmet Newsletter , says that “they are usually somewhat higher plus they add a massive service charge and very often, a gratuity.”

Larry Olmsted, author of the bestselling Real Food Fake Food, falls into that higher-priced camp as well, noting that “in many cases, the exact same dishes are priced higher on the room service menu than in the hotel restaurants.”

The culprit may be the add-ons that make room service seem like an expensive indulgence.

Alexander Lobrano, a Paris-based food writer and restaurant critic whose newsletter is Hungry for Paris, says that room service prices “aren't usually that far off those of prices in the restaurant.”

He insists that it is those extras that can make for an expensive tab when you order that club sandwich or bowl of pasta and have it sent up to your room. What drives the prices up “is the fine print of service charges, tray charges and other ways of making you pay for the pleasure of private dining, something that most hotels have pretty much fallen out of love with because it's logistically complicated.”

Those fees, add Olmsted, might include “a service fee comparable to what you would tip downstairs, plus an ‘in-room dining’ surcharge, often in the $5-12 range, means it almost always costs more to dine in.”


Five myths about hotel room service

Important stuff you should know before you ring down to the desk.

There’s nothing quite like hotel room service. Be it an indulgence or a necessity, few things seem better suited to serve a jet-lagged traveler than a freshly delivered breakfast tray or a late-night sandwich. While seasoned road warriors may have their room service routines down to a science, many of us pause before picking up the phone to order. Maybe it’s the fact that room service food can seem incredibly expensive, take forever to get to the room and is often tepid and less than tasty when it finally arrives. Here are five myths about room service.

1. Room service menu prices are identical to those in the hotel’s restaurant.

It sure doesn’t seem that way. John Mariani, the legendary food critic and author of Mariani’s Virtual Gourmet Newsletter , says that “they are usually somewhat higher plus they add a massive service charge and very often, a gratuity.”

Larry Olmsted, author of the bestselling Real Food Fake Food, falls into that higher-priced camp as well, noting that “in many cases, the exact same dishes are priced higher on the room service menu than in the hotel restaurants.”

The culprit may be the add-ons that make room service seem like an expensive indulgence.

Alexander Lobrano, a Paris-based food writer and restaurant critic whose newsletter is Hungry for Paris, says that room service prices “aren't usually that far off those of prices in the restaurant.”

He insists that it is those extras that can make for an expensive tab when you order that club sandwich or bowl of pasta and have it sent up to your room. What drives the prices up “is the fine print of service charges, tray charges and other ways of making you pay for the pleasure of private dining, something that most hotels have pretty much fallen out of love with because it's logistically complicated.”

Those fees, add Olmsted, might include “a service fee comparable to what you would tip downstairs, plus an ‘in-room dining’ surcharge, often in the $5-12 range, means it almost always costs more to dine in.”


Why Wildly Expensive Room Service Still Loses Hotels Money

Apparently, the New York Hilton Midtown will no longer be offering room service. So customers will no longer have the option of ordering cookies and milk for $20. That’s got to be a lucrative business, right? Maybe not. Check out this report from Marketplace.

This quote from the report gets to the heart of the problem.

“It’s very rare, if not impossible, for hotels to produce revenue in terms of room service,” says Mehmet Erdem, professor at the Harrah College of Hotel Administration at University of Nevada, Las Vegas.

Hotels typically lose money keeping a full kitchen and wait staff on standby. That’s the key reason hospitality watchers believe hotels are killing room service. In many cases, that means job cuts for hotel workers, 55 at the New York Hilton alone. For its part, Hilton says it’s ending room service because of declining demand.

In essence, an in-room dining operation suffers from being a small-scale queuing system that needs to deliver a high service level (and thus is not unrelated to our earlier discussion of Tesla’s charging stations). Queuing system’s benefit from economies of scale so as the arrival rate goes up the total capacity needed to deliver a desired service level increases but that capacity will be more heavily utilized. Going the other way, if the Hilton experienced decreasing demand, it could shed some workers but not enough to get the utilization level back up to what it once was. The cost of providing the service consequently increased. Thus it is not that it costs $20 to get a cookie up to a guest’s room but that it is expensive to have staff spending a lot of time not bringing cookies up to someone’s room. The unscheduled nature of room service further complicates the problem. A restaurant can smooth out the flow of orders by using reservations or strategically delaying moving patrons from the bar to a table. The in-room dining staff has to take the orders as they are called in.

There are a lot of (primarily local) services that face similar issues. Think about a plumbing emergency. If you call a plumber asking for immediate service, you will likely be quoted a very high rate. It is natural to surmise that the price is jacked up because you just told them that you are literally up shit creek, but except in the smallest of towns, plumbing is a competitive business (unlike room service at a particular hotel). One firm would presumably have an incentive to cut its rate a little, dominate the local plumbing emergency market, and probably win a loyal following for mundane, scheduled work. That doesn’t happen — presumably because having skilled tradesmen sitting around underutilized waiting for an emergency call is just too expensive.


13 Items They Made During the Great Depression (But We Pay for Now)

It may seem as if making homemade items instead of buying them is more expensive, but you save in more ways than at the grocery store. Homemade items are usually healthier which can save you money on healthcare costs. Yes, you may pay for more for supplies in the very beginning, but unless the item is food, they generally last much longer than store-bought since they require a smaller amount to work.

Bread – During the depression, bread wasn’t bought at a store for most families. Instead, they made their favorite homemade bread recipes at home. It was and still is cheaper to make your own bread per loaf than to buy it. They also had many recipes they made with bread to save money.

Biscuits and Rolls – Biscuits and rolls might fall under bread for some, but for others, they’re a separate item. In any case, they weren’t paid for during the Depression. Like bread, they used their favorite biscuit recipes and favorite homemade dinner rolls recipes to make them if they wanted to have them with dinner.

Shampoo – During the depression, the bottled shampoo wasn’t a big thing so women either made their own homemade shampoo or they simply used baking soda and water to get their hair clean. Even today there are some who still use this old tried & true method of cleaning their hair.

Canned Soup – Before the invention of microwaves and convenience products, the canned soup wasn’t the norm. Instead, during the Depression, they made it themselves by using their favorite soup recipes. A can of soup will cost you at least $1.00 per serving, but when you make it homemade, you cut that cost in half.

Diapers – Disposable diapers didn’t happen in the Depression. Instead, most families used some form of cloth diapers. Even now, cloth diapers are often cheaper for families than disposables if you have a reliable way to wash them.

Baby Wipes – Baby wipes weren’t used in the Depression either. Moms who had little ones simply used a washcloth to clean their baby. If your budget is tight and you’re looking to save money, there is no reason that you can’t as well.

Microwave Popcorn – If you wanted a popcorn snack during the Depression, you didn’t pop a bag in the microwave. Instead, you bought real popcorn kernels and had to pop it on the stove or an open fire. Microwave popcorn is pretty cheap, but by purchasing popcorn kernels in bulk and making them yourself, you’ll pay around the same amount for three times the popcorn.

Canned or Frozen vegetables – Back during the Great Depression, canned or frozen vegetables weren’t a thing and instead, those families generally grew the vegetables that they ate. If they needed to preserve them for the winter, they used tried and true canning recipes to do so instead of relying on a commercial canner.

All-purpose cleaners – During the Depression, most families didn’t pop out to the store when they needed a bottle of cleaner. Instead, they cleaned with vinegar, baking soda, or a homemade all-purpose cleaner. Not only were they cheaper but they are healthier too.

Floor Cleaners – Moms during the Depression didn’t have separate floor cleaners either. Again, they used plain water or white vinegar. If you feel like you need a little more to get your floors clean, a good homemade floor cleaner recipe is a great start that is super budget-friendly.

Window cleaner – Families who lived during the depression didn’t buy window cleaner either. Instead, they used a homemade window cleaner or something simpler.

Laundry Detergent – That liquid detergent sitting on your laundry room shelf wasn’t around during the Depression either. Instead, they made homemade laundry detergent or used a bar of soap such as Zote to clean their clothes. For that matter, commercial washers and dryers weren’t all that common either. If a family was lucky enough to have a washer, it was an old school wringer washer and clothes were dried on a clothesline.

Can you think of any other items that they made homemade during the Great Depression but we buy today?


How does a $25 room service burger not make money?

Room service is coming to an end at the New York Hilton Midtown. In August, the city’s largest hotel will become perhaps the highest-profile property to cut out in-room dining. But scores of hotels have axed the service, citing slowing demand.

Some new hotels don’t bother to offer it at all. At the Wythe Hotel in Brooklyn’s endlessly-hyped Williamsburg neighborhood, hungry hipsters can’t dial up a late breakfast in bed. The owner says he wants people to be part of the buzzing scene at the restaurant below, not gobble omelets while watching reality TV.

Losing the luxury of room service will disappoint some business travelers (spending their company’s expense account, naturally) and children fascinated by the elegant steel plate covers and adorable little condiment jars.

Latest Stories on Marketplace

It also means the end of a perk that has provided some memorable cinematic moments. The world’s most famous spy orders room service frequently. But if James Bond checks into the Hilton and hungers for a healthy breakfast of “green figs, yogurt, coffee, very black” — as he did in “From Russia with Love” — 007 will have to get take out and bring it up himself.

To find out why room service is dying out, Marketplace sent me to the Hilton on a sensitive reporting mission: Persuade strangers to invite me into their room to order food.

Fresh out of a harrowing cab ride from JFK, Australian visitors Suzette and Aynsley Waldock agreed to let me buy them room service while they unpacked. This is their first visit to New York.

“Ridiculous, way, way, way too expensive,” Suzette Waldock laughs as she scans the menu.

But Marketplace is paying, so we end up ordering a turkey club. Another item demands explanation: Cookies and milk. $20. I was deeply curious as to why these cookies were so expensive. But the guy taking our order wasn’t much of a salesman.

“I don’t know,” he concluded. “That’s what the price is.”

We bought them anyway. I offered a few sightseeing tips while waiting for the knock at the door. Finally, a gentleman in crisp uniform wheeled in the feast. Before us stood one $24 turkey club and the aforementioned cookie plate, an assortment of several types that were warm and appeared to be homemade.

Tack on an “in room dining charge” of $11, an $8.25 service charge, tax and a generous tip, and this was an $80 meal. You could just hear Marketplace’s accountants grinding their teeth.

At these prices, one might think the hotel is making a killing. Unlikely.

“It’s very rare, if not impossible, for hotels to produce revenue in terms of room service,” says Mehmet Erdem, professor at the Harrah College of Hotel Administration at University of Nevada, Las Vegas.

Hotels typically lose money keeping a full kitchen and wait staff on standby. That’s the key reason hospitality watchers believe hotels are killing room service. In many cases, that means job cuts for hotel workers, 55 at the New York Hilton alone. For its part, Hilton says it’s ending room service because of declining demand.

That means the Waldocks will be among the last to sample this hotel’s expensive cookies and milk. They urged me to take some food with me. I declined, but when they insisted, I tried an oatmeal raisin cookie, the most expensive of my life. It was pretty good, though not the best I’d ever had. But since it came via room service, it’s part of a vanishing breed and as such, was something special.


Think the E.R. Is Expensive? Look at How Much It Costs to Get There

Kira Milas has no idea who called 911, summoning an ambulance filled with emergency medical technicians. Ms. Milas, 23, was working as a swim instructor for the summer and had swum into the side of the pool, breaking three teeth.

Shaken, she accepted the ambulance ride to Scripps Memorial Hospital in La Jolla, Calif. The paramedics applied a neck brace as a precaution.

A week later she received a bill for the 15-minute trip: $1,772.42. Though her employer’s workers’ compensation will cover the bill, she still was stunned at the charge. “We only drove nine miles and it was a non-life-threatening injury,” she said in a phone interview. “I needed absolutely no emergency treatment.”

Thirty years ago ambulance rides were generally provided free of charge, underwritten by taxpayers as a municipal service or provided by volunteers. Today, like the rest of the health care system in the United States, most ambulance services operate as businesses and contribute to America’s escalating medical bills. Often, they are a high-cost prequel to expensive emergency room visits.

Although ambulances are often requested by a bystander or summoned by 911 dispatchers, they are almost always billed to the patient involved. And the charges, as well as insurance coverage, range widely, from zero to tens of thousands of dollars.

“There are a significant numbers of patients who have no coverage for this, and the number of self-pay patients has climbed” since the recession, said Jay Fitch, president of Fitch and Associates, the largest emergency medical services consulting firm in the United States.

Image

What is more, since ambulances companies typically collect only 30 to 40 percent of the amount they bill, they often try to charge more for patients with insurance and those who can pay, Mr. Fitch said.

Part of the inconsistency in pricing stems from the fact that ambulance services are variously run by fire departments, hospitals, private companies and volunteer groups. Some services are included in insurance networks, others not.

“There’s a saying that if you’ve seen one emergency medical system, you’ve seen one emergency medical system — no two are alike,” said Dr. Robert E. O’Connor, a vice president of the American College of Emergency Medicine and chairman of the department at the University of Virginia. Charges and payments, he said, “are all over the place.” Fire departments, which don’t charge for driving to fire alarms, do charge for ambulance runs.

In such a fragmented system, it is hard to know how much high-priced ambulance transport contributes nationally to America’s $2.7 trillion health care bill. And total out-of-pocket expenditures by individuals are hard to tally.

But Medicare, the insurance program for the elderly, does tabulate its numbers and has become alarmed at its fast-rising expenditures for ambulance rides: nearly $6 billion a year, up from just $2 billion in 2002.

That is true even though Medicare’s fixed payments for ambulance rides — ranging from $289 to $481 in 2011 — are far lower than commercial rates. Ambulance companies complain that Medicare rates do not meet the costs of running what are essentially mobile emergency rooms staffed by highly trained professionals.

In a recent study, the federal Health and Human Services Department’s Office of the Inspector General noted that the Medicare ambulance services were “vulnerable to abuse and fraud,” in part because there were lax standards on when an ambulance was needed and how the trip should be billed. The number of transports paid for by Medicare increased 69 percent between 2002 and 2011, while the number of Medicare patients increased only 7 percent during that period. In the last year, two ambulance companies have pleaded guilty or settled claims for overbilling Medicare.

The Affordable Care Act requires policies to include some coverage for emergency care as an essential benefit, including ambulance transport. But the ambulance ride and the care are billed separately. Many Silver plans — a lower-tier plan — require patients to pay an initial copay of $250 for the emergency room and $250 more for the transport, for example.

Every insurance plan evaluates ambulance rides differently for coverage, with many seeking to determine if the service was really needed — a true “emergency.”

That determination can be highly subjective. Some will grant coverage if the destination was an emergency room, regardless of the patient’s status, but others may require admittance to the hospital as evidence that the condition was serious. “Insurers will generally cover if you had good reason to believe there was a serious threat to your life or health,” said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, an industry group.

But when an ambulance arrives, sick patients or injured people like Ms. Milas, often feel they have little choice but to get in, unaware of the potential price tag.

If an emergency call comes to 911, dispatchers decide which ambulance to send, depending on proximity. Most ambulance companies bill according to the level of skill of the team on board, rather than the medical needs of the patients they collect. A team capable of administering Advanced Cardiac Life Support costs more than one with only basic first aid training.

Distance rarely counts for much, although a small mileage charge is added to the fee. Some companies even charge hundreds of dollars extra if a friend or relative rides along with an injured patients.

This fall, Joanne Freedman went to an urgent care center near her home in New York City with a bad headache and a fever. The doctor recommended she go to a hospital for further evaluation and offered to call an ambulance.

“I could have walked, but I’m feeling crummy so I think, ' OK, why not?’ ” she recalled.

The two-block ride was billed at $900, and she has not yet learned what her insurer may ask her to pay.

“It was crazy,” she said. “All they did was put a paper mask on me so I wouldn’t infect anyone else.” Ms. Freedman had a spinal tap at the hospital and was admitted for a few days. Nonetheless, she said, for $900, the next time, no matter how ill she will walk up the hill or take a cab.