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Of all the ERs in all the SSM hospitals in the region, only the ones at Cardinal Glennon and St. Louis University Hospital are actually run by SSM.

In the first sentence of her story in Sunday’s Post-Dispatch about lawsuits filed against patients who’ve used SSM Health emergency rooms, reporter Samantha Liss used the phrase “Las Vegas-based collection firm.” That looked ominous, especially for low-income patients now being squeezed by debt collectors.

SSM, the area’s second-largest health care system, outsourced emergency room care at most of its area hospitals to Schumacher Clinical Partners of Lafayette, La., in 2008. SSM retained responsibility for emergency care at Cardinal Glennon Children’s Hospital. Last September, it acquired St. Louis University Hospital from Tenet Healthcare Corp. and runs the ER there as well.

In 2014, Schumacher sold an undisclosed amount of uncollected debt to CP Medical LLC of Las Vegas, a unit of Capio Partners of Duluth, Ga.

In the unholy mess that is the American health care system, none of this is unusual. Lots of people take bites of the apple, a big reason why the apple is so expensive. Running emergency rooms is complicated, so hospital systems often outsource the job to private firms. They hire and bill for the doctors and nurses.

Patients get a bill from SSM for using the facilities, and separate bills from the medical contracting firm for professional services. Add laboratories, insurance companies and benefits managers to the mix, it gets very confusing.

Collecting medical debt, even the co-pays and deductibles from patients who are insured, is complicated and time-consuming. After months and years go by, firms like Schumacher sell the debt — often for pennies on the dollar — to firms that specialize in collecting debt.

What’s troubling here is that CP Medical has, between December 2014 and March this year, filed at least 1,078 lawsuits in the circuit courts of St. Louis city and county. If the debtor doesn’t show up in court — and most don’t — the judge can order the defendant’s wages and bank accounts garnisheed.

Robert Swearingen, an attorney for Legal Services of Eastern Missouri, told Liss, “I hardly ever see medical debt in St. Louis.”

CP Medical counts on defendants not showing up in court. “They’re a default judgment machine,” Swearingen said.

The Las Vegas-based collection firm is playing the odds. If you buy a million dollars worth of debt for $50,000, you have to collect only 10 percent to double your money.

This is not SSM’s fault, but it gets the black eye. As a not-for-profit, it is obligated to provide certain levels of charitable care to justify its tax-exempt status. But Schumacher, its ER contractor, is under no such obligation. A spokesman for the company said that if it learns that SSM gives the patient a break on the hospital bill, Schumacher will match it on the medical care bill.

Once a bill gets to that Las Vegas-based collection firm, all bets are off. That’s a roulette wheel rigged to ensure the most vulnerable patients lose every time.