The Case of the $7,600.29 Cookie

A story (paywall) in today’s Morning News hit close to home for me. It’s about the goofy billing practices of hospitals. The gist:

Some Dallas hospitals charge five times as much as hospitals just a few miles away for the same treatments, federal data released Wednesday shows [sic]. In 2011, Medical City Dallas Hospital charged $430,219 for Medicare respiratory patients using a ventilator for more than four days. Baylor Medical Center in Irving, meanwhile, charged an average of $82,185 for the same treatment. … [F]ederal health officials [say] the data shows [sic] disparities that have no adequate explanation.

“There is no relationship we see in the variation in charges and the quality of care that’s being provided,” said Jonathan Blum, director of the Center for Medicare in the U.S. Department of Health and Human Services. “We want to shine a much brighter light on practices that don’t seem to make sense to us from a consumer standpoint.”

I read the story with interest because yesterday I got a $6,935.29 bill from Medical City and another $665.00 bill from an associated outfit. My 7-year-old daughter, who is allergic to nuts, had eaten half a nut-filled cookie, and I’d taken her to the Medical City Children’s ER. I hasten to mention that every one of the medical professionals we dealt with, from the admissions staff to the docs, was great. My daughter got the care she needed in a timely manner. The staff was helpful and patient. But the itemized bill is truly a thing of wonder.

First, if you care, here’s how the cookie thing went down: it is a Saturday in April. We are at a backyard crawfish boil. My daughter — who has been to the ER before for reactions to nuts, who has had it drilled into her head that she is never to eat sweets of unknown provenance — walks up to me, tears welling in her eyes, and says, “Daddy, my mouth is itchy, and I think I ate nuts.” Then she holds aloft the half-eaten cookie, which clearly has nuts in it. There is much crying. There is Benadryl. There is a phone consult with the out-of-town wife, which leads to a Pulp Fiction-style administration of adrenaline via the dreaded EpiPen. This produces a level of shrieking and bleeding that other guests clearly don’t enjoy. Then — oddly, Daddy thinks — the little girl wants to go back into the bounce house, which Daddy allows because Daddy has no idea how the EpiPen works. Bad call. Very bad call. Because what follows is vomiting and racing to the ER, as the little girl develops anaphylaxis and turns red from her chest to her knees.

So the folks at the Medical City Children’s ER quite possibly saved my daughter’s life. Again, good show on their part. After getting some more adrenaline and steroids through an IV, my daughter was eventually admitted to the hospital, where together we spent a not terribly restful night. Which brings me to the bill for the cookie (really half a cookie). After spending about 45 minutes on the phone with a helpful BlueCross BlueShield rep, I now understand the charges as follows:

$665.00 — doctor (what the ER doc is paid, separate from hospital)
$3,034.25 — emergency room services (what the hospital charges to visit the ER)
$1,954.00 — room charges (no minibar, just a room for a night)
$563.17 — pharmacy IV solutions (self-explanatory, though the drugs themselves aren’t listed)
$350.37 — pharmacy general (no idea, BlueCross didn’t know)
$143.00 — med/surg sterile supply
$890.50 — IV therapy general (BlueCross guessed that this was the process of using the IV, as opposed to the drugs administered thereby)

You are wondering, so I will tell you. After meeting our deductible and after the capping of some of these costs per the contract between Medical City and BlueCross, I am responsible for $1,904.61. If you look at that as the price for keeping my daughter alive, it’s a bargain. No question about that. If, on the other hand, you see that number as the cost of half a freaking cookie, and if you roll up the many pages of the BlueCross explanation of benefits, fashioning a homemade EOB truncheon that you brandish at your daughter, and if you menacingly spit through your teeth, “If you ever decide to make a judgment call on a cookie again without first asking an adult, I will …,” before cutting yourself short because it’s not cool to threaten a 7-year-old — well, you can’t do that. You just can’t. Right?

I’ve asked for a better itemized list of charges from the hospital. I want to know what “pharmacy general” is, for instance. But it looks like I now have two choices. The billing operation for Medical City tells me that if I pay it all immediately, they’ll knock 20 percent off the top, saving me $380. Or I can pay as little as $100 per month until we’re square. In other words, I can get screwed now, quickly, violently, or I can get screwed slowly, over the next year and a half. I put it to you, dear readers: why did I wait as long as I did to get a vasectomy?

(Full disclosure: I love the ever-living crap out of my daughter, and while this bill has temporarily driven me insane, I really am grateful for how everything turned out. If you have a kid who’s allergic to nuts, don’t get lackadaisical, as we did, about toting around the EpiPen. Special thanks to the Cramers for letting me borrow theirs.)


  • Brett Moore

    Glad everything turned out OK with your kiddo, Tim.

    It’s not, of course, just emergency care or medical billing that’s so bizarre. It’s the entire healthcare industry.

    For example – I’m a Type 1 Diabetic (that’s the non-preventable one that used to be known as Juvenile Diabetes, before I hear any comments…)

    Because I know I have an expensive condition (without insurance, my monthly for insulin, pump supplies, test strips, etc would be about $1000), so my wife and I pay for the top insurance we can get. The good stuff – I mean the $100 deductible annually stuff.

    Even with that incredible insurance, I’ll occasionally get a bill for lab fees for my blood work of $900. This only gets taken care of after an inordinate amount of wrangling and fighting with the insurance company, the lab, my physician, etc.

    Why? Why is this all so freaking complicated?

  • David Malphurs

    That’s not the price for half a cookie. It’s the price for your daughter not being properly supervised and eating something she was allergic to. Not the hospital’s fault. Also, you got the best care you could get IN THE ENTIRE WORLD. Oh, and one more thing: as I can attest too, vasectomies don’t always work. My surprise daughter is staring at me right now.

    • FIJ

      Is the point of you saying this to argue that healthcare costs in this country make sense? Because they don’t.

    • Tim Rogers

      Sorry about the vasectomy snafu, David. God’s plan and all, right? Vishnu’s plan?

      Sure, sure. As I said, she got great care. But this isn’t complicated stuff. You got a kiddo with an allergic reaction, you hook her up to an IV, and you monitor her vitals. The drugs aren’t that expensive. The machines involved aren’t exotic. It simply shouldn’t cost $7,000 — even if you’re paying for the expertise in case the situation DOES get more complicated.

    • SJWside

      Wow – so clueless and uninformed. It’s a losing battle for you to try and argue that the price of healthcare in the US isn’t disproportionate. And no, Medical City Hospital is not the best healthcare in the entire world (or Dallas for that matter). Nor does the US have the best healthcare in the entire world (I’m guessing you probably haven’t even been outside of the US… ever). If that were the case, the US wouldn’t rank low on life expectancy of industrialized countries. We definitely have the most expensive healthcare but not to the best. Turn off Fox News and you could learn something factual.

    • Harvey Lacey

      I think you’ve had too much Bush/Rushade for your own good. We do not have the best in the world, unless of course your gauge is cost.

  • AtoZ

    If your nut-avoidance instructions to your seven-year-old actually incorporated the word “provenance,” I think I have an idea where your program broke down.

  • Bill Marvel

    The best of luck with your new daughter, David. Because if she’s anything like a normal child, you’re in for some very unpleasant — and expensive — encounters with the health care system, no matter how closely you think you are “properly” supervising her, no matter how allergy-free you imagine her to be. The hubris, the ungenerous tone of your comment here suggest you are either very, very young or have led a blinkered life.
    But as i say, best of luck.

  • Cole Daugherty

    *Forehead Slap*
    This isn’t about a child eating a cookie nor is about someone having a heart attack because they enjoyed southern fried chicken nor another person suffering from cancer because their parents passed along a gene. Quit the blame. Everyone will need care at some point (immediate or not, blamess or not) so what is it about the system that is so nefarious and how can we start by diagnosing the problem? I encourage everyone to read Steven Brill’s recent examination of this question in Time magazine:,9171,2136864,00.html

  • Tim Rogers

    Cole, that Brill article is right on point. So is this “This American Life” episode from 2009.

  • Tim Rogers

    No, I used that word for a comedic effect that apparently wasn’t effective (on you). My nut-avoidance instructions actually involved a three-act marionette play starring an orange octopus and a character named Mr. McNutt. The first and second acts are pretty straightforward (girl eats Mr. McNutt, girl gets itchy mouth, etc.), but the third act gets very dark in a Samuel Beckett-y sort of way, and the girl dies in a puddle of her own vomit. It’s funnier than it sounds.

  • Tim Christnagel

    I’m so glad you are being promoted back to a full time writer.

  • N Dallas mom of 3

    So glad everything turned out ok with your daughter…the hospital stuff is maddening and I second you on the emergency care received by Medical City. I just have to say that I am probably not the only mom that is smiling (only knowing after everything is ok) and secretly happy that it happened on the dad’s watch! By the way, my husband would have done the same…

  • Tim Rogers

    Heck, that means a lot to me. Especially coming from a fellow Tim. Really, thanks.

  • Paul

    So, just where do you think better care is on offer? For example, when the King of Saudi Arabia needed back surgery, where do you think he went? Hint: it wasn’t Canada, France or the UK. M.D. Anderson regularly treats folks who’ve traveled half way around the world for world class treatment. The typical American has insurance (for now at least) that gives them access to the same great care. Turn off MSNBC and you might learn something.

  • SJWside

    Gee what a great argument. A King has medical care at MD Anderson. What about the people of this country? Who gives a rats as* about where a King gets medical care. That doesn’t say how the people of this country receive care. Why don’t you look at where the World Health Organization ranked the US health care system? The typical American doesn’t have affordable insurance. You may, and I may but the typical American doesn’t. Just the facts.

  • Peter Kurilecz

    back in 1990 we discovered that my daughter was highly highly allergic to sesame seeds and peanuts. Her reaction to sesame seed (tahini sauce) was so fast during the scratch test the allergist couldn’t start his stopwatch. from that point on we carried epipens everywhere (they work 50% of the time) we also drilled it into her head to never eat something for which she didn’t know the contents. we had to rush to the hospital once after she wiped her hand on a table where there had been peanut butter (nothing could be seen on the table). she touched her lip and it immediately began to swell. Twenty some odd years later I still worry about her and her allergies

  • Peter Kurilecz

    and why do we have the medical bills we do today? where ever little pill is priced? look to Medicare. Once he government started paying the bills they wanted to know the unit cost. prior to Medicare many of these costs were lumped together. you didn’t charge for a single aspiriin tablet or kleenex etc. then the insurance companies stepped in to throw another layer of complexity onto the problem. Ask a hospital/doctor/whomever how much a certain procedure will cost and they can’t tell you until it is done and sent to the billing department

  • Peter Kurilecz

    sorry SJWside but you’ll have to stop listening to the President and his troops
    “In October 2008, candidate Obama used the study to claim that “29 other countries have a higher life expectancy and 38 other nations have lower infant mortality rates.” ”
    “World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all. The report’s true achievement was to rank countries according to their alignment with a specific political and economic ideal—socialized medicine—and then claim it was an objective measure of “quality.””
    Health Myth #1: “The U.S. has one of the highest infant mortality rates in the developed world.”

  • Peter Kurilecz

    ” The typical American doesn’t have affordable insurance” and who do we have to thank for that? why the state and federal govenments along with the American public who demands that health insurance cover every little procedure known and unknown to man. this would be like having car insurance pay for tire inflation, rotation, window washer fluid replacement etc.
    health insurance should be for catastrophic reasons not hangnails

  • Cody Shawver

    I think the biggest mistake was giving her an adrenaline shot and not epinephrine, how you got adrenaline inside an Epi pen the world may never know.

  • Harvey Lacey

    Ah Timmy, it’s about overhead, we all have it. I can scream to the heavens about paying five bucks for thirty cents worth of paper and ignore the rent Wick pays for the D offices, the salaries of his wannabe like Timmys.

    A month or so ago I had an “event”. Nine pm on a Saturday and all of sudden there were two putters, pair of balls heading for two cups. I had double vision. Wife went into that mode you have to deal with when you marry a widow.

    Everyone said it was a stroke and I needed to be kept for observation and tests. The MRI revealed I had a piece of steal in my head that wasn’t there a year ago, itty bitty piece, but it really made the MRI screen shot special, think of one of those horror movies where the victim has a big hole in their head, bound to happen when you’re a fabricator/clutz. It had nothing to do with the event but it sure got the MRI techs talking. We got a CAT scan, MRI, sonograms of the carotid arterys, follow up visits with neurologist, cardiologist, twice, etc and so on.

    Bottom line, I’m fine and we don’t know what happened, TIA of some kind. Bill is over $20,000.00 now. In the hospital I was asked at least a dozen times why I was there, cognizant thing I’m sure.

    “I have great insurance.”

  • Harvey Lacey

    One the overhead thing Tim, imagine what you would have to have for a copy of D if Wick insisted upon owning your own printing shop, distribution vehicles, etc? That’s what the medical thing is about. Instead of having a shared piece of equipment each hospital has to have their own.

    Vijay Govindarajan’s book Reverse Innovation talks about a hospital in India that does open heart surgery for $5,000.00. At that price they make enough to afford any charity case that comes to the door and still make a profit.

    Oh. And their rate of success is greater than the best hospitals in the States too. They also have better rates when it comes to infections etc.

    It’s all about efficiency, their equipment is used 24 hours a day, not four or five times a week. Their surgeons have done thousands of successful surgeries, not five hundred in ten years like a real deal pro here in the States. They’re so profitable that they are considering opening up facilities off shore to make money off of Americans who want better service at a fraction of the cost that they can get in the States.

  • Dr. Yes

    Why are you so unhappy and confused, little mortals?

    You want more life? I can sell it to you – at my price.

    If you get angry at me, I might complain to the gods of fortune and you and your children might die anyway, even having paid my price.

    So best you get angry at something other than me and the cost of life I’m selling you, if you know what’s good for you. How about those insurance companies. Or the Republicans. Or the Democrats. Yes, that’s better. You certainly don’t want me to get petulant and refuse you my gift of life, do you? That’s a good little mortal.

    • Dr. No

      So I get that you’re roleplaying as some sort of weird Lovecraftian/trickster spirit doctor, but the root cause here isn’t individual greed- it’s the fee for service system combined with disincentives for managing patient populations well.

      An example would be self-pay patients who pay so much more in comparison to the discounted rates that large MCOs are able to negotiate because they have bargaining power, uninsured rarely go to the hospital until things are terrible, meaning more drastic (and costly) interventions are necessary.

      Don’t be mad at individual doctors for this- it’s not useful, even if it is gratifying to try and graft problems onto one person or group of people.

  • Daniel Hopkins

    My son’s skull fracture totaled $20,000, of which BCBS covered $15,000. It was basically two nights of monitoring in the new Children’s Neurology building. When they sent us home, they told us he’ll get better on his own. Worth every penny, of course, but $20,000 for 2 nights of monitoring?

    Oh yeah, we had some cat scans, but those aren’t that expensive are they?

  • Jen

    Got a bill for the Children’s Medical Center ER; $60 for adhesive for the Pulse Ox. That’s TAPE, and despite the good care she good got…that’s not OK. When you get your itemized pharmacy bill, you will probably notice that you got charged $12 for ONE Tylenol.

  • Neal K

    You make some good points, but there are two problems. First, unlike a magazine that sells advertising and is purchased only by people who want to buy it, Tim’s health care costs were indirectly subsidized by everyone else covered under Blue Cross policies (in the case of Medicare, the costs are subsidized by taxpayers). And there is nothing wrong with that at all – that is the nature of insurance. In order for the insurance business model to be sustainable, risks are spread around the larger pool of insureds. But that doesn’t mean we shouldn’t be concerned about pricing. Higher costs mean higher premiums.

    Second, there is tremendous pricing disparity among hospitals. Some of the disparity has to do with quality of care and facilities, but it is still very arbitrary. I have no problem with hospitals trying to make a profit. I don’t want to go to a for-profit hospital that loses money. But if consumers could easily compare costs of the same services from one hospital to another, I think there would be some competitive pressure on the hospitals to cut costs – if nothing else, they might do so out of sheer embarrassment.

  • seriously?

    So America has good doctors that have benefitted from our university programs, that work in specialist clinics and are very talented. Okay, but that genuinely has nothing to do with what the level of care (or debt) that the Average Person might receive at any given point of time while still being charged out of their ears for necessary care. Are you then implying that places with more manageable care, where patients aren’t regularly shafted when they get the bill for life-saving work, do not have any great private practice doctors?

    There are always going to be specialist practices that can’t cater to the vast majority of people with average insurance, either because of price or location of said practice. The fact that the King of Saudi Arabia came to the US for back surgery says nothing – of course he did, who wouldn’t seek a better level of care if they could afford it? The problem is that the average person doesn’t have these liberties, and the average American is less likely to receive preventative care in the early stages of an illness’ development because of health insurance costs- whereas in the UK, Canada or France, regular health check ups are nowhere near as expensive as they are here. So your point is- well- pointless.

  • KTN

    I think AtoZ was also attempting to be humorous, but in a geeky sort of adult vs. kid language sort of way. Don’t take it to heart – I believe he/she understands your darkly funny comment explaining behavior modification in the adult context.
    Do you have a video of that McNutt play, by the way? I’m seeing it as a PSA between segments on Fox News or MSNBC. Take your pick which political segment you’d like to offend more. That was my attempt at being funny, but I may have to use an emoticon to keep it on the lighter side… 😉

  • Paul

    Ever hear of the show called “Let’s Make a Deal”? That’s what this is. Hospitals have absolutely no idea of costs. They work on the principal of let’s through the pasta on the wall and see what sticks.

    I once had to go to the hospital ER, err excuse me — urgent care, to have a nail removed from my finger. The bill was for $1,800, yet the hospital in question was willing to settle for $650 from my health care provider.

    I guess that this is what happens when you have an onsite pharmacy at your place of work …