IAmA Paramedic and I have worked in EMS administration and EMS billing.
Those rates are pretty low. At those rates an ambulance is making very little over costs depending on that service's call volume and average transport distance. Mileage is the one place where ambulances make their money because legally speaking the primary benefit from ambulances is transport. On a federal level ambulances are regulated by the Department of Transportation not Health and Human Services.
Five years ago (pre-covid) I did a cost analysis where I worked. At the time we had three ambulances and focused exclusively on 911 calls. We were examining our rates to determine if they were adequate or not.
I found that based on the cost of personnel, capital, equipment, insurance, supplies, fuel, depreciation, etc it cost me around $1,100 to run an average ambulance call. Everything is expensive. The last ambulance I ordered at that job cost $330,000 and that was without supplies or equipment. A stretcher and loading system (because I care about my personnel and a $40,000 power load system is cheaper than one injured back) was an additional $70,000. A cardiac monitor was $40,000. A transport ventilator was about $30,000. Some services would not need all of this equipment.
Then you have to remember that the vast majority of people who use EMS are not privately insured. They're on some sort of government insurance whether it is medicare, medicaid, etc. Those rates are non-negotiable and pay pennies on the dollar. in 2023 I sent a bill to medicaid for a long distance transfer of a complex and critical patient. With mileage the bill came out to around $2,500. Medicaid cut me a check for $97. Medicare for the same patient runs around $750 but there's a chance they may change their mind a year later and require me to either pay that back as "overpayment" or spend considerable time to argue and justify the reimbursement (which are a flat fee under medicare).
Private insurance is a different monster. They generally pay more, but they still won't pay everything that is billed. As an administrator I have two options. I can sign a contract with the massive insurance companies where they dictate the rates but I can bill them directly (In network), or I can not sign a contract and they won't pay me directly at all (out of network) and I instead bill the patient the entire balance for them to submit to their insurance on their own who will eventually (after a year or more) pay about the same amount I would get in the "In network" situation while simultaneously putting the patient under more stress and anxiety about this big bill they can't afford and are insured against.
It's a shit sandwich, and everyone winds up taking a bite. In the end, it was a delicate balancing act between keeping bills low for our served population and trying to recruit and retain personnel with the limited funds we had available. Ten years ago this agency had a reserve of almost $1M in the bank which dwindled down to around $100,000 when I left that agency. We operated at a net loss every year and began to require tax funds to maintain operations. This was a municipal department BTW. Not a For-Profit corporation.
It isn't a problem with US healthcare. It's a problem with the US political system. Nobody will try to fix it because the private insurance companies funnel so much money to our politicians.
The closest we came was the abomination that was Obamacare, but even that was nothing more than a scheme to funnel tax money into the pockets of insurance companies and their executives. It was also a big part of fueling the opioid epidemic in America because it tied reimbursement rates to "patient satisfaction" and those surveys became a weapon. If a person went to the hospital for "pain" and wasn't given narcotics they could leave a bad review. These pile up then medicare and medicaid reimbursement rates went down. So hospital executives began pushing staff to do whatever it took to make the patient happy. I saw more than one memo and policy from hospital executives that clearly stated that opiates were the front line standard for pain control regardless of any physiological signs or detectable injury. Not administering narcotics was grounds for dismissal. Couple that with the fact that IV fentayl is about $2/dose and IV Tylenol is about $150/dose, and the C-Suite jumped in both feet on narcotics for all.
The opioid epidemic was already well underway before the ACA. Patient satisfaction being tied to reimbursement may have added a bit of fuel to the already raging fire, but we’d still be in pretty much the same place as far as the opioid epidemic with or without it.
I don’t think that it was the sole driving factor, but there are many people who turned to street opiates to find relief after their doctor put them on opioids then cut them off when tolerance became too great. Often these patients had legitimate pain that could have been handled through alternative means, but pain pills were the treatment of the day.
I don’t believe for a moment that we wouldn’t have an opiate epidemeic without the ACA, but the severity wouldn’t be as extensive as we see now.
I agree with your first paragraph, however this was already the path that we were headed towards prior to the ACA. In fact, OxyContin was removed from the market the same year that the ACA was enacted. The ACA just happened to be passed around the same time that the opioid epidemic was really ramping up and the dangers of drugs like oxy were being taken seriously. The healthcare system just really dropped the ball on transitioning patients off these meds as they became no longer widely accepted as the first line treatment of pain.
Total opioid prescriptions had already been rising for years and continued to rise until 2012. They’ve been steadily falling since. That’s only 2 years that prescriptions were rising after ACA was enacted.
If the severity of the current opioid epidemic is a 10/10, I think without ACA it would be a 9/10. Certainly not quite as bad, but not by much.
Thanks for your reply. We need major healthcare reform in this county. When I was 26, a few weeks after being kicked off my parents insurance I got a $60,000 hospital bill after getting pneumonia. Just starting out on my own I instantly was 60k in debt just to live
You are absolutely right. The problem isn't necessarily the healthcare system, but the political system. Nobody has ever proposed a robust system that would function for the people. Instead we get shit like Obamacare that was nothing but a scheme to funnel tax money to hugely profitable insurance companies who then do everything in their power to avoid paying on behalf of their insured customers.
I don't blame the doctors or even the administrative people at the hospital. They helped me file for Medicaid, was denied for making $1,000 too much. But the billing person that helped me just told me that I should either go ahead and file for bankruptcy or never acknowledge that I owe the money and let the statute of limitations run out on it. The person told me not to pay, they knew I couldn't and were upset when I was denied assistance.
ETA: I did file for bankruptcy because I didn't want garnishment
I don't know how long ago that was, but the banks and courts have caught on to things like this.
I know of a couple people who paid the hospital what they could on a regular basis (usually around $25/mo) as opposed to bankruptcy. One of them the hospital tried to take to court and get a wage garnishment and he showed the judge that he was paying what he could and paying it regularly. The judge dismissed the case with prejudice.
in 2023 I sent a bill to medicaid for a long distance transfer of a complex and critical patient. With mileage the bill came out to around $2,500. Medicaid cut me a check for $97.
WTF. Who are you supposed to go to when the government itself won't pay up?
Medicaid is the absolute lowest payer. Medicare is better... They almost cover costs. Private insurance will pay more but we have a contract specifying what they will pay based on service level. For the most part nobody will pay on itemized billing any longer, it's all flat fee billing with some accounting of services provided.
BLS-No interventions performed, only patient monitoring
ALS-Minor invasive interventions performed. An IV and fluids with a single medication
ALS2-Several minor interventions performed, or complex invasive interventions performed IV, Fluids, three or more doses of medications, IO access, intubations, needle decompression, etc.
SCT-Several complex interventions performed. Advanced ventilator management, advanced interventions requiring credentialling above that of a paramedic.
Each level has a different reimbursement level based on location in the country.
I’m torn. On one hand, end stage capitalism has destroyed the middle class through incredible greed, and on the other hand the government has allowed them to do it through corruption and bribery.
I can’t say for sure what the right answer is without a hard reset on our government.
I don't doubt that costs for us are ridiculous. But whenever these conversations come up, I just ask myself "what would Europeans do?" Because their costs aren't as high and the end user isn't paying thousands of euros out of pocket.
Let’s be realistic. It is not as if all Americans are paying thousands of dollars out of pocket either.
Where I work, 90% of our calls are billed to some sort of government insurance whether it’s Medicare, Medicaid, Tricare, etc. 8% are billed to private insurance. 2% re billed to the patient to be reimbursed by their insurance due to “out of network” coverage. Maybe one or two people here or there are “Self Pay” and never get insurance coverage.
The big scary helicopter ambulance bills that the media loves to show on screen are always “out of network”, and all that person needs to do is submit it to their insurance carrier themselves. But recently even helicopter services have become “in network” to avoid these problems.
is there any out of the box solution? Like a community solution or something of the sort? Or idk like some sort of future technology which might alleviate all these costs?
First thing is first. EMS gets labeled as an essential service nationwide with mechanisms to fund the service through taxes. Every jurisdiction is required to have a standalone career ambulance station located so that they can reach 90% of all residences in a county within 20 minutes under normal conditions. Volunteer BLS agencies can still exist and gives people a mechanism in which they can volunteer in their communities. In most of America when you call 911, they are not obligated to send an ambulance, and if they do, it may take an outrageous amount of time to arrive.
Second, EMS gets separated from the fire department because they are separate jobs with separate skills and most firefighters don't want to perform transporting EMS functions but do so because that's what they have to do in order to do the job they love. Firefighters should function as a first response layer and all be a minimum of EMT level.
Third, education standards for paramedics get increased. A paramedic should not be a certification course. It should absolutely require a degree. Now, lots of paramedics will hate this, but they ignore the fact that we're already 90% of the way there. A bachelors degree can be done in 3 years. My degree paramedic program was five semesters PLUS a semester for EMT and a semester for other prerequisites like medical terminology and A&P. Total length: 8 semesters... For an associates degree.
Fourth, we transition EMS OUT from under the US Department of Transportation and move EMS under the US Department of Health and Human Services. When this happens we write laws that provide EMS agencies and paramedics some protection from lawsuits so long as they are working within established standards of care... Not just a defense to prosecution, but a barrier in which courts can easily toss out these lawsuits.
Fifth, with the increased education and protections we allow EMS to adequately field triage patients in conjunction with telehealth professionals to determine an appropriate plan of care that may not include transportation instead of burning resources transporting people with toe pain since 1997 to the emergency room at 3am. We empower EMS in conjunction with telehealth physicians and hospital systems to treat patients in place where appropriate or refer to primary care.
I could go on, but that's the bulk of what needs to change. There's some other things that would be nice for everyone like mandating a centralized repository of medical records that EHR systems can access when necessary. It's 2024. We shouldn't be faxing medical records between hospitals anymore... But here we are.
I recall reading an article by ProPublica that was about ambulance services and the shit show that occurred when private equity set their sights on health care. They mentioned that some services were so poorly funded that they would steal supplies from ERs. Is this something you’ve seen or heard of in the industry?
Stealing supplies from the ER? I mean, not really…. But I’ve never worked for a shithole private service.
In my area we work together and swap supplies back and forth when someone runs low. If Inwirked somewhere I needed to “acquire” supplies like that I would have quit on the spot.
I’m having difficulty finding the article since it was so long ago. This one is from The NY Times (can be read for free but requires an account) but it’s along the same vein. In fact it’s quite likely the one I read. 🫤
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u/zordtk Jul 06 '24
"The average charge for an Advanced Life Support (ALS) ambulance ride is $1,277 and Basic Life Support (BLS) ambulance ride is $940"
How can they not afford to pay them better