- Uninsured heart attack, stroke patients face ‘catastrophic’ costs
- Broke and Uninsured: My Visit to the ER
- Getting Sick: A Horror Story
- Uninsured: Affording Healthcare
- Uninsured: America’s Youth
- Amy Chyan: In the ER
- Healthcare Bills are ‘Crippling’
- Surviving Without Insurance
- A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack
- Heart Attack Treatment Cost
Uninsured heart attack, stroke patients face ‘catastrophic’ costs
“Many patients with large medical bills may have had to declare bankruptcy, sell their home, and be hounded by medical bill collectors as they struggled to juggle rent or mortgage payments while paying for utilities and food,” said cardiologist Dr. Rohan Khera, an Internal Medicine fellow at UT Southwestern Medical Center and co-first author of the paper, “Medical expenses are the leading cause of bankruptcy in the United States.”
For uninsured patients hospitalized with acute myocardial infarction (heart attack), the median cost for their stay totaled $53,384 in 2012, according to the research. Uninsured stroke patients had a median bill of $31,218.
Modest weight gains — even among those who aren’t overweight — can cause dangerous changes to the heart, but small amounts of weight loss can improve the condition.
Based on the likely annual incomes of the uninsured patients, which were modeled on the median incomes of their residential zip codes, the researchers estimated that 85 percent of the heart attack patients and 75 percent of the stroke patients faced hospital bills greater than 40 percent of the income they had left after buying food.
About 60 percent of the uninsured heart attack patients had bills higher than their annual income, after allowing for the purchase of food, according to the paper.
“The potentially devastating financial impact of these events on the uninsured is considerable,” according to the paper, which pointed out that more than 1 in 8 of heart attack and stroke patients were without insurance before the Affordable Care Act (ACA).
The research, published in the journal Circulation, looked at thousands of patients hospitalized for acute myocardial infarction (heart attack) or stroke between 2008 and 2012, the year before Americans began signing up for subsidized insurance on exchanges created under the federal Affordable Care Act (ACA).
The patients studied ranged from age 18 to 64 (federal Medicare insurance is available to those 65 and older). More than 39,000 hospitalizations for heart attack and more than 29,000 hospitalizations for stroke were analyzed.
Information for the paper came from the National Inpatient Sample, a large database developed by the federal Agency for Healthcare Research and Quality.
Collaborators included cardiologist Dr. James de Lemos, Professor of Internal Medicine and holder of the Sweetheart Ball‐Kern Wildenthal, M.D., Ph.D. Distinguished Chair in Cardiology and Medical Director for the Dallas Heart Study, and researchers were from Baptist Health South Florida, Johns Hopkins Bloomberg School of Public Health, Florida International University, Michael E. DeBakey VA Medical Center, Brigham and Women’s Hospital, and Yale New Haven Hospital.
Broke and Uninsured: My Visit to the ER
The pain in my chest intensifies. My heart is beating so fast I feel as if there are guppies jumping out of my throat. My extremities tingle, and I become light headed. I squat down so I don’t faint and knock myself out.
I Google my symptoms, clicking on the first link under “chest pain on left side.” Everything points to heart problems. I start to panic, wondering how I will pay for a visit to the ER if I need it.
I am unemployed, uninsured, and I might be having a heart attack.
Getting Sick: A Horror Story
As a non-resident from Canada, my coping mechanism for getting sick in New York City is to simply… not. When I do come down with the flu, I end up staying in bed and relying on the only remedy I know: Nyquil, Gatorade and the fetal position with lots of movie-watching in bed.
Today was different. Today I might’ve actually worried myself sick because I was scared about how expensive the hospital would be.
My non-American friends and I like to trade horror stories of paying obscene amounts to go see the doctor. I am not an anomaly when it comes to not being able to afford healthcare.
Uninsured: Affording Healthcare
Almost 16 percent of Americans are uninsured, and the number of employer-sponsored insurance is also dropping, according to the U.S. Census Bureau. That means 48.6 million Americans are without health insurance, and it’s affecting our youth.
The group most likely to be uninsured is young adults ages 19 to 34, according to a 2012 nationwide survey report by the U.S. Department of Health and Human Services. Uninsured rates were highest among part-time workers and the unemployed, although one in seven full-time workers is also uninsured.
It’s $1,000 for blood work here, $30,000 for an appendectomy there. These stories are passed around like warning tales, and we grimace in unison and quickly vow to never get sick.
Uninsured: America’s Youth
Bianca Consunji, an associate video producer at the online publication Mashable, recently received full-time benefits. But as an intern and freelancer, she had no healthcare benefits and depended on over-the-counter medications.
“I developed back pains from sitting at the desk for long hours and carrying heavy equipment for shooting, but I can’t do anything until I’m insured,” Consunji said. “I lived in perpetual fear of getting into a serious accident and being unable to afford treatment.”
Sherry Glied, the Dean of New York University Wagner and former Professor of Healthy Policy and Management at Columbia’s Mailman School of Public Health, acknowledges the increase of freelancers and college graduates without insurance. Children under 26 can stay on their parents’ plan, and starting in January 2014, they’ll be able to get insurance, she said.
But what can parents without insurance do for their children? Non-group health insurance plans, though expensive, may be an option, Glied said.
“Just hope you don’t get sick before January,” she added. “It’s a very scary thing for families without insurance. A lot of people end up going bankrupt.”
Amy Chyan: In the ER
The walk from my room to the nearest hospital is a reasonable five-minute walk, but it felt like 10 seconds in my panic. It was as if the fast forward button was on. Once in the ER, the register puts on my hospital bracelet on and lies me down for an EKG. The stern nurse is not happy when I fidget out of nervousness. She scolds me three times for moving and says, “What’s more important, your life or your phone?”
I chose a seat right by the entrance of the ER’s wait room. A woman on a wheelchair is squirming and screaming. The nurses don’t pay attention. A homeless woman is sleeping in the far corner, her luggage in tow. I debate whether to call my parents again.
Every step of the way, I make sure to let the nurse or the register know I am uninsured.
Healthcare Bills are ‘Crippling’
My 10 hours in the ER boil down to blood tests, chest x-rays, a lot of waiting and more blood tests. The diagnoses is that I had an anxiety attack because of the chest pain, though source of pain is still a mystery and needs to be followed up with a cardiologist.
After a year of interning for free full time, paying for graduate school tuition and living in Manhattan, an uninsured hospital bill can be financially and mentally crippling. My bill amounted to about $2,300.
Would this anxiety attack have happened if I was in back home in Toronto and knew I had access to free emergency care? It’s tough to say. But certainly every time I don’t feel well in New York, I am faced with the high cost of healthcare.
Surviving Without Insurance
For those who are uninsured and earnestly waiting for the Affordable Care Act , here are some tips for survival:
1. Healthy Diet and Exercise An apple a day will not always keep the doctor away, but a healthy diet paired with exercise will keep your immune system performing at its best.
To reap the health benefits of physical activity, one must combine aerobic and muscle-strengthening activities, according to the U.S. Department of Health and Human Services. Physical activity can prevent heart disease, type 2 diabetes and help control blood pressure, blood sugar, and weight.
Children and teenagers should get an hour or more of physical activity each day, which can be spread out throughout the day, according to the Centers for Disease Control and Prevention. Adults are recommended to engage in five hours of exercise per week, mixing aerobic workouts and strength training for maximum benefits.
Eat a diet that is low in fat, high in whole grains and well balanced with lean proteins and leafy veggies. Avoid sugary beverages or soda. Instead, snack on healthy alternatives like fresh fruits and vegetables, low-fat cheese, yogurt and nuts and seeds.
2. Rest Know when to rest. If you feel the pre-symptoms of the flu, like the aches and shivers, take a day off to let your body take care of itself.
3. Have An Emergency Contact Hopefully you’re lucky enough to have a friend nearby that can be you emergency contact. A familiar face in an unnerving hospital setting is always comforting.
4. Financial Assistance For those that are uninsured, many hospitals have financial assistance programs based on annual income. Meet with the financial counselor, they will help you figure out the best payment plan for you and your family.
A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack
UPDATE: This story has an addendum reflecting the hospital’s latest settlement offer.
Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.
Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.
“I thought I was dying,” the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using his voice, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David’s Medical Center on April 2, 2017.
The ER doctors confirmed the trauma to Calver’s heart and admitted him to the hospital’s cardiac unit. The next day, doctors implanted stents in his clogged “widow-maker” artery.
The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.
Despite the surprise, even from his hospital bed, Calver asked whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David’s is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.
The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.
And then the bills came.
Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.
Service Provider: St. David’s HealthCare, a large hospital system in central Texas. It’s run by HCA Healthcare, the nation’s largest for-profit hospital chain, and two nonprofit foundations.
Medical Treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks, because they are so frequently deadly.
What Gives: St. David’s Medical Center is billing Calver for the $109,000 balance — an amount nearly twice his annual pay as a teacher.
The hospital’s billing company sent a notice June 26, urging him to take advantage of this “FINAL opportunity to settle your balance.”
“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”
In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans, even as legislators have tried to protect them: surprise bills and balance billing.
Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.
The total bill for Drew Calver’s four-day hospital stay at St. David’s Medical Center in April 2017 was $164,941.(Callie Richmond for KHN)
His insurer paid $55,840, leaving Calver responsible for the unpaid balance of $108,951.31.(Callie Richmond for KHN)
Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.
But there’s a huge loophole: Those state-mandated protections typically don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or employers pay claims out of their own funds. Federal law governs most of those health plans — and it does not include such protections.
About 60 percent of people with employer health benefits are covered by self-insured plans, but many don’t even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.
Drew Calver sits with his wife, Erin, and daughters Eleanor (left) and Emory (middle) in their Austin, Texas, home where he had a heart attack on April 2, 2017.(Callie Richmond for KHN)
This case “illustrates the dangers that even insured people face,” said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. “The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in.”
In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.
“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.
Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David’s said once ER patients are deemed stable, it tries to transfer them to an in-network facility. “However, this is not always possible because the patient’s health must come first,” the hospital said.
This case also raises questions about the validity of the hospital’s charges.
Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. “This is a well-known, problematic provider. We’ve seen multiple bills from them and they are always highly inflated,” said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.
WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.
Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David’s Medical Center charged four times that amount.
Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.
St. David’s charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.
The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.
“St. David’s charge of over $19,000 for those stents is absolutely outrageous,” Quarum said.
St. David’s declined to comment on its markup for the stents or what it actually paid the manufacturer.
Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.
In fact, the hospital’s debt collector sent the Calvers a letter Aug. 3 demanding payment in full.
After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.
In a statement, St. David’s said “we work with all patients needing financial assistance to help determine their eligibility for this discount.”
Calver said that approach doesn’t address the balance billing or whether the charges were appropriate.
A spokeswoman for Aetna said “we are actively working to rectify the situation on behalf of the member.” But the health plan hasn’t shared any further details. The Austin school district declined to discuss this specific case.
Calver said the whole ordeal has been incredibly stressful for him and his wife.
“I am stuck in the middle of this convoluted, flawed system,” he said. “I’ve never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?”
Drew Calver’s daughters visit him at the hospital in April 2017 after his heart attack and resulting emergency surgery.(Courtesy of the Calver family)
The Takeaway: Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive. First, let the insurance process play out completely so you’re sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.
Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.
If the bills keep coming, talk to your employer’s benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.
With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.
Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills.
Ashley Lopez, a reporter with NPR member station KUT in Austin, contributed to the audio story in this report.
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
UPDATE: Monday, shortly after publication and broadcast of this story by Kaiser Health News and NPR, St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.” In a statement, the hospital said this offer was contingent on Calver submitting his application for a discount based on his household finances. Calver disputed that he owed any additional money to St. David’s. By Thursday, the hospital had slashed the bill to $332.29, which Calver paid off over the phone, he said.
Cost and Quality Health Industry Insurance Bill Of The Month Emergency Medicine Hospitals
Heart Attack Treatment Cost
- According to the National Heart, Lung and Blood Institute, heart attack treatment works best when it’s given right after symptoms occur, and a patient experiencing an attack should be taken to the emergency room or transported there by ambulance.
- For patients without health insurance, an emergency room visit typically costs $150 -$3,000 or more, depending on the severity of the condition and what diagnostic tests and treatment are performed. For patients covered by health insurance, out-of-pocket cost for an emergency room visit typically consists of a copay, usually $50 -$150 or more, which often is waived if the patient is admitted to the hospital. Depending on the plan, costs might include coinsurance of 10% to 50%.
- In the ER, a doctor may administer a “super aspirin” such as clopidogrel (Plavix) , which, according to Consumer Reports typically costs $254 per month for one 75 mg pill per day. Or, an ER doctor may give the patient nitroglycerin tablets , which typically cost $.20-$1.10 per pill.
- According to theAgency for Healthcare Research and Quality , the average length of hospitalization and related costs for heart attack patients is 5.3 days at $21,500 per stay. Costs for patients with insurance may include a deductible, plus 10%-20% or more of the total bill, which could easily reach the yearly out-of-pocket maximum. Treatment will vary depending on the severity of the condition and amount of heart damage present.
- Patients may be treated with a category of intravenous drugs known as thrombolytics or clotbusters. According to a study in the medical journal Stroke, the additional costs of thrombolysis (using medication to break up and dissolve blood clots) during the first hospitalization costs approximately $5,978 per patient. Doctors may administer other drugs, including intravenous or subcutaneous forms of the anti-coagulant heparin. According to the book “Hospital Medicine” by Robert M. Wachter, Lee Goldman, and Harry Hollander, this can include Dalteparin (Fragmin) , which typically costs $51 a day for 100 U/kg twice daily, and Enoxaparin (Lovenox) which typically costs $55 a day for 1 mg/kg twice daily. Treatment may also include drugs called beta blockers , which typically cost $6 -$170 per month depending on whether a generic or brand name drug is used, or statins , which according to Consumer Reports , cost $35- $200 or more a month.
- Other medical procedures that may be required include bypass?surgery (about?$70,000-$200,000); corrective?heart?surgery ($30,000-$200,000 or more);?and treatment with angioplasty?and stents?($11,000-$41,000?or more).
Related articles: Chest X-Ray, MRI, Heart Stent, Heart Surgery, Heart Bypass Surgery, Emergency Room Visit
My friend Chuck, a retirement planner, had a mild heart attack a few weekends ago. His experience has had a profound impact on his view of the rest of his life, so I asked him if I could share his insights with our readers. Here goes.
“I used to eat too much of the wrong things,” Chuck told me, “too many greasy foods and too many sweets. I told people it was my ‘cancer prevention’ program. I figured I’d most likely die from either cancer or heart failure, and given a choice, I’d much rather die of heart failure. So eating heart-unhealthy foods was the best way to avoid dying from cancer. It was partly a joke, but mainly a weak excuse for not being disciplined about the bad foods I loved to eat.
“When I turned fifty and was already distinctly overweight, I decided I didn’t need to keep fighting the battle–who was I trying to impress? So I showed even less restraint with my diet, and quickly gained another ten or fifteen pounds. But I realized that the heavier I got, the worse I felt, so for the past five or six years, I’ve been eating more moderately and getting more exercise. I’ve lost almost 40 pounds. But I’ve continued to avoid going to doctors or having routine diagnostic tests.
“Recently, after two hours of heavy yard work, I felt a tight spot in my chest, along with a few, milder symptoms. I suspected a heart attack but didn’t really believe it. It wasn’t until the next day, when some symptoms were persisting, that I even called my doctor, who told me to go right to the emergency room, where a heart attack was confirmed.
“The bad news is, since I didn’t get to the hospital fast enough, there’s permanent damage to the heart. But it’s localized to the part of the heart that does the least work, and the tests showed my heart was still pumping at full strength. I need to go on some meds, but within two months, the doctor thinks I can be back at even the most vigorous physical tasks. I still need to make some permanent changes in my life, particularly my diet and exercise habits. Overall, I got off lucky.”
Even though Chuck was lucky, he paid a big price for denial. First, by avoiding a healthy lifestyle for the past few decades, and second, by denying that it could be a serious event at the time of his heart attack. Let’s do some math to estimate the price of denial of his unhealthy lifestyle.
According to an article from the National Business Group on Health, the average total cost of a severe heart attack–including direct and indirect costs–is about $1 million. Direct costs include charges for hospitals, doctors and prescription drugs, while the indirect costs include lost productivity and time away from work. The average cost of a less severe heart attack is about $760,000. Amortized over 20 years, that’s $50,000 per year for a severe heart attack and $38,000 per year for a less severe heart attack.
You might argue that insurance will pay for a large part of the direct costs, but whatever assumptions you make about those costs, you’re still looking at a high annual cost of denial. You might also argue that healthy food costs more than unhealthy food, but the difference can’t possibly make up for the high cost of denial. And who can put a price on your health or a damaged heart?
“I’m glad to share my experience if it can help others,” Chuck told me. “I learned this lesson the hard way–maybe others can learn it a little easier than I did.”
If you’ve had a similar experience that can help our readers, I invite you to write a comment below. It might save some lives — and at the very least, it might save some people a whole lot of money.
When you or a family member are feeling sick and need health care now, it can be hard to know where to go. Many people immediately think they should go to the emergency room. But many health care issues can be more easily treated at an urgent care clinic. In fact, one national study found that 27% of all emergency room visits could have been taken care of at an urgent care clinic.
When to Go to the Nearest Urgent Care Clinic
Urgent care clinics offer quick, affordable treatment for non-emergency health issues. Urgent care clinics are open nights and weekends and most, like AppleCare, do not require appointments.
Here are some examples of non-emergency health issues urgent care clinics can treat:
- Cold or flu-like symptoms
- Sprains and strains
- Shallow cuts
- Urinary tract infections
- Insect bites
- Vomiting or diarrhea
- Minor burns
- Fractures and dislocations
If you are experiencing a non-emergency health issue, an urgent care clinic is a better choice than an emergency room. Here are two benefits of using an urgent care clinic near you:
- Urgent care clinics have a shorter wait time. Emergency rooms are designed for emergencies, which take a while to treat. The average emergency room visit will take over 2 hours, while the majority (85%) of urgent care visits take an hour or less.
- Urgent care clinics cost less. Did you know the average emergency room visit costs $1,389? That’s nearly 4 times higher than it was just 10 years ago! Even if you have insurance, an urgent care clinic will still probably cost you less due to the lower co-pays.
When to Go to the Emergency Room
Emergency rooms, also called emergency departments, are meant to be used for true medical emergencies. Some examples of medical emergencies include:
- Chest pain
- Difficulty breathing
- Deep cuts
- Gunshot wounds
- Serious burns
- Bleeding that you cannot control
- Drug overdoses
- Head trauma
If you believe you or someone near you is experiencing a medical emergency, visit an emergency room as soon as possible.
Visiting an emergency room may also be your best option if it is very late at night or early in the morning. Although urgent care clinics are open nights and weekends, emergency rooms are open 24 hours a day, every day of the year.
When to Call 911
There are times when it is best to call 911 instead of trying to drive to an emergency room or an urgent care clinic. If you are experiencing any of the following health issues, please call 911:
- Blurry or lost vision
- Bleeding that you cannot control
- Chest pain
- Suspected heart attack or stroke
We know it’s stressful when you or a family member are sick. If you are experiencing a non-emergency health issue, walk in to any of our convenient AppleCare Clinics that are open days, nights, and weekends. Our friendly doctors and health care staff will have you feeling better in no time!
How many emergency department visits could be managed at urgent care centers and retail clinics?
Emergency department wait times, crowding, and access
Urgent Care Association 2018 survey responses
‘Really astonishing’: Average cost of hospital ER visit surges 176% in a decade, report says