Trauma tax revenues leave imagers cold

January 17, 2006

"I would like to discuss my mother's bill."

"I would like to discuss my mother's bill."

"Would you like to pay by cash, credit card, or check? If you are going to pay by check, we will need two photo IDs."

"No, I don't want to pay her bill. It is totally wrong, and I just want to get it fixed."

"Yes, sir. That will cost you $3.99 a minute to discuss the problem. Will you be paying by . . ."

"What? You want me to pay just to talk to you about a mistake you made on her bill?"

"Yes. However, if you pay by cash, we can offer a one-tenth percent discount."

"Are you crazy?"

"Oh, I forgot. Did your mother smoke?"


"Oh, good. Because of the California Emergency Services Tobacco Tax, state residents only have to pay $3.79 a minute. So will that . . ."

"We are just here from Ohio for . . ."

"Oh, dear. I am sorry, but out-of-state residents are charged $9.99 per minute."

"When you talk to my lawyer, it's going to cost a lot more than $9.99 a minute. My mother received a bill for more than $24,000, and half of that is a 'trauma activation fee.'"

"Yes, sir. Whenever the emergency medical technicians alert the hospital they are coming from the scene of a motor vehicle accident, the trauma team is immediately activated. The client is charged whether or not the team actually treats the patient."

"Oh, really! And what about the charges for CT scans of the head, neck, chest, abdomen, and pelvis? And the drugs, IVs, and EKGs?"

"These are all standard charges, sir."

"For a dead woman?"

"I am sorry that your mother died, sir, but the charges are accurate."

"That's where my lawyer is going to have a field day, because my mother was already dead. Her hearse was involved in the accident, and her body was thrown from her casket! What do you think of that?"

"We knew that."


"Yes. Our doctors practice the best defensive medicine there is, and had to be sure she was in fact dead. We wouldn't want to be sued for missing any injuries if the funeral home made a mistake or she was just faking it."

This hypothetical may be exaggerated but it is based on a real event first reported by a San Francisco ABC television station. Don Cohon, a Marin, CA, resident, was bicycling when his front tire suddenly blew. He was thrown from his bike and suffered a temporary loss of consciousness. He was taken to Marin General Hospital, where he spent about three hours. He received a bill for more than $24,000, of which $12,420 was a "trauma activation" fee. The fee was characterized by the hospital as "neither a time nor a resource-based fee." This means that if the EMT in the ambulance categorizes a patient as a trauma case, the fee will be applied automatically.

I have been unable to find a single radiologist who has ever heard of this fee, but in California, it is becoming more common. Granted, Marin General has one of the highest. John Muir Medical Center in Walnut Creek, CA, charges $7600, while Stanford Medical Center's fee is a steal at only $2000. Some hospitals offer choices. Queen of the Valley Hospital in Napa, CA, charges $1700 for a "low level" activation and nearly $6000 for a "high level" activation, according to the ABC news report. So who is getting all this money? It's not the radiologists, even though they are essential to trauma response.

A bill under debate by the state legislature, the Emergency Services and Tobacco Tax Act of 2006, is sponsored by 450 hospitals in California to raise money for emergency services. Some of that money will make its way to radiologists, right? Wrong. A portion of this tax will be used to cover fees that specialists are increasingly demanding in exchange for being on call. These fees increased 10% to 25% per year in some parts of the country. Some fees are as high as $3000 a night.

Good Samaritan Hospital in San Jose, CA, has on-call agreements with 12 subspecialties, at a cost of $4.5 million per year, according to CEO William Piche (San Jose Business Journal, Oct. 21, 2005). Keep in mind that 10 years ago, no hospitals were paying doctors to be on call. Specialists realized that to keep their practices healthy, they had to provide on-call service, since 25% to 40% of their business derives from ER visits. But with increasing costs and insurance cuts, doctors are looking for additional sources of income.

The argument against paying radiologists for on-call duty is that they have an exclusive contract. But radiologists are also losing revenue, because that contract is being breached as many imaging services are doled out to specialists. One of my group practice clients recently saw its vascular imaging services handed over to the vascular surgeons' group, which more than likely is also receiving on-call stipends.

In a survey by the American College of Physician Executives, 46.6% of hospitals are paying fees to specialists to be on call, and 46.4% are considering doing so. Why does this matter? Congress and the Bush administration are faced with a ballooning federal deficit and increasing medical costs. The president, senators, and representatives are all looking for issues to revitalize government and engage the public.

Centrists and the left want to expand healthcare coverage for Americans. Conservatives want to decrease government spending with large Medicare and Medicaid cuts. These would seem to be mutually exclusive topics. But many hospitals have found that they can squeeze radiologists to give up income to other specialists and make them work harder at the same time.

So what do you need to do? March down to your emergency department and find out who does the billing. Ask that person if the hospital has an emergency activation fee or if it is considering levying one. If so, how is that charge determined and who shares in the revenue? If you are told that the radiology department is not included, you should start asking why not.

Next, find out which specialists in your hospital are being paid to be on call. How much are they receiving per night? Keep in mind that information about these arrangements is often considered as classified as a CIA agent under deep cover. It may take some creative digging to find out all the pertinent details. (Scooter, where are you?)

If you don't ask these questions and look out for your own radiology practice, no one else will. In a world where radiologists are being bled dry, your lifeless body may end up in the morgue-not with a toe tag attached, but instead with a bill from the very people who put you there.

Dr. Trefelner is a radiologist and cofounder of NightShift Radiology. He invites comments by e-mail at or fax at 650/728-5099. He also answers questions posed by readers in the "Ask Eric" column on