Ben Taub General Hospital in Houston runs one of America's most distinguished trauma centers, taking on thousands of severely injured patients every year.
Forty miles north, Conroe Regional Medical Center qualifies as a trauma center under Texas law, but no one would put it among the nation's most sophisticated. It isn't staffed to do the kinds of complex surgeries done at Ben Taub. It is set up, instead, to stabilize the toughest cases and transfer them.
You wouldn't know that by the bill.
For "trauma response," a fee charged when a medical team is paged to await a patient, the world-renowned Ben Taub last year charged an average of $2,781.
Conroe Regional charged $19,604, the highest average fee in the state.
This disparity isn't unique to Houston, or even Texas, a new Tampa Bay Times analysis has found. It reigns across America.
Earlier this year, the Times detailed how hospitals in Florida are exploiting trauma fees, which are levied like a cover charge just to get in the door.
Floridians have been charged as much as $33,000 depending on where the ambulance pulls up. The fee winds up on the bill, even if the patient needs little more than first aid.
To find out what hospitals across the nation are charging, the Times collected public records from 10 states and contacted hundreds of hospitals in states that couldn't provide the records.
The bottom line: The same scenario is repeating itself across the country, as more and more trauma centers recognize the fee for what it is — a completely unregulated source of revenue.
The fee is growing at a rate some experts describe as absurd.
And there's little reason for it to stop.
'A conservative start'
Twelve years ago, the argument for a trauma fee made sense.
America was raw from terrorist attack, and specialized hospitals across the country — the very places set up to treat victims of such disasters — were closing their trauma centers, citing the high costs of running them.
Unlike emergency rooms, trauma centers must be able to field a team within minutes to treat complicated injuries from crashes and shootings. This means paying specialists to be on call, even when they aren't needed.
Hospitals traditionally get paid only for the services they perform. The trauma fee was created to help cash-strapped hospitals recoup "readiness" costs.
The problem is, no one created clear rules for what a hospital could charge. And virtually no one regulates the fee.
Maryland runs a unique system that sets hospital rates based on costs. It's been heralded for some of the lowest charges and insurance premiums in the country. Trauma response fees are not used there.
It doesn't take much to see the fee has grown out of control.
Medicare pays about $1,000.
National Foundation for Trauma Care, the group that pushed for the fee in 2002, told its members a "conservative start" was $3,500 to $5,000.
In comparison, the average fee in Florida last year was $10,000.
Across America, the numbers are climbing even higher.
Last year, Loma Linda University Medical Center in California's San Bernardino Valley listed its "Trauma Activation Level A" fee as $64,900.
Spokesman Tony Yang said looking at one fee is unfair.
"Because each hospital may take a different approach in determining what is included in the activation fee, we believe it's not an apples to apples comparison," Yang said. "We believe a more fair and accurate approach is to compare total charges."
Connie Potter, a consultant who helped create the fee, disagrees. She said trauma centers of the same level should have comparable fees.
This year, Loma Linda's fee jumped nearly $13,000 — to $77,880.
"Goodness," Potter said, "I've created a monster."
A Times analysis
To analyze fees, the Times gathered numbers from a variety of sources. Some states, like California, allow the public to search through price lists. Others, including Arizona, collect data on what every patient is charged.
The newspaper ultimately examined the fees of 267 trauma hospitals in 30 states, including more than a third of the country's major centers.
Most charge more than the "conservative start" once advocated by the fee's creators. Almost one in five examined by the Times charges at least $15,000.
Top-level hospitals often charge thousands less than lower-level centers.
Have a wine-fueled mishap in California's Napa Valley?
You may wind up at Queen of the Valley Medical Center, a Level III trauma center not required to staff the kinds of specialists needed at a major center. It charges about $21,000.
The fee is $3,676 at Massachusetts General, a Level I trauma center that trains Harvard Medical School doctors and triaged the injuries of 39 Boston Marathon bombing victims.
In cases like this, geography may explain part of the disparity. The center in Napa is surrounded by high-charging hospitals; the one in Boston is not.
In other cases, the hospital's owner determines the charge. The Times found that for-profit hospitals, on average, charge more than nonprofits.
Among the highest chargers is Hospital Corporation of America, one of the nation's largest for-profit hospital chains.
Its hospitals in Florida, Nevada and Texas top price lists, even though none are designated as top-level trauma centers.
One of the best windows into the fee's growth comes from the group that created it, now called the Trauma Center Association of America.
The association surveys its member trauma centers every three years to find out how much they charge. The Times obtained the confidential 2014 report from an association member. In it, the group concludes that trauma fees have increased 87 percent in six years, or 15 percent per year.
"This is an enormous increase in charges, far in excess of the average growth of medical expenditure," said Zack Cooper, a Yale University professor who studies hospital pricing.
The association does not publish the identities of the trauma centers that disclose their fees. But in 2007, the highest fee it came across was $24,964.
In 2013, $47,546.
Potter told the Times she couldn't fathom a hospital justifying that charge based on costs.
"That could mean they're flying in trauma surgeons in Learjets for the night," she said.
Hospitals rarely collect every cent of what appears on a bill. But most told the association that insurers pay a percentage of charges, an arrangement the Times found in Florida.
The more hospitals charge, the more they stand to make.
Jennifer Ward, president of the trauma association, noted that the median fee charged by the hospitals surveyed by her organization in 2013 was $7,738.
She said hospitals routinely set reasonable fees based on costs. However, she said the association does not support fees in excess of what's needed to operate a trauma centers and would support "the development of a different payment methodology to ensure adequate and appropriate payment in an effort to contain costs."
A California father recently went public about a $10,000 trauma fee, which showed up on his hospital bill after his 3-year-old son spent just two hours in the emergency room.
Eric Michael David, a doctor and a lawyer, knew his son didn't need a trauma team to address the week-old bruise on his head, he wrote in the Wall Street Journal in September. And even though his insurance company paid most of the bill — "a huge failing" — he decided to fight it.
He spent weeks arguing with the hospital, which only dropped the fee after he studied billing codes and pointed out his son's case didn't meet an important requirement. No one had called in the emergency in advance.
According to several people involved in creating the fee, it can only be charged when that happens, triggering a team to assemble before a patient arrives.
"If you want to bill $10,000 for a trauma team, you can't unilaterally decide that the patient required a trauma team," David wrote. "That would be like a supermarket being able to require you to buy $10,000 worth of chicken because they decide that's what you're hungry for."
The trauma association survey suggests this is happening elsewhere, with hospital officials reporting that insurers questioned their fees when a patient walked away without an injury, and when the patient showed up without advance notification.
Hospital officials told the trauma association that insurance companies are increasingly raising questions. One in five of the surveyed trauma centers reported being told the charge wasn't medically necessary at least once.
The trauma association survey backs up what the Times found in Florida, where thousands of people were charged the trauma fee even though they stayed at the hospital only a few hours and needed minor medical care.
Potter said insurance companies will eventually crack down on the overcharging and in the process may hurt hospitals charging reasonable fees.
"The only money trauma has ever had is going to go down the dumpster because of sheer greed," she said.
Hospital officials in Florida admitted that they could not justify their fees based on actual costs. Instead, some said they increased their fees simply because they saw other hospitals charging more.
There's no sign that will change, based on reaction from some hospital officials.
"Could you send me a link to the final story?" asked Chuck Gill, vice president of public affairs at Central Maine Healthcare, whose medical center in Lewiston charges a trauma fee of $819.
"Maybe we need to raise our prices."
Times computer-assisted reporting specialist Connie Humburg contributed to this report. Alexandra Zayas can be reached at firstname.lastname@example.org or (727) 893-8413.