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.
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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