Why American ambulance rides are so expensive

He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.

As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice.

My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.

This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.

We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.

> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.

The author does not understand how private equity extracts money. The high-liability and heavily scrutinized business is intentionally left with little profit: the actual profits are funneled up the supply chain. This is why private equity buys "nonprofit" hospitals - they can now control who that nonprofit buys services and equipment from.

As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted. The article starts off by noting about how ambulance is an "option" for a rescue, but even though the analogy might vaguely work, it's not really needed to answer the question. That can be answered far more simply: "medicare and insurance companies pay them too little, so they have to charge everyone else more". Or, from the article:

>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]

>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.

I worked at a company which was doing medical billing for ambulances among other things.

Essentially, the bills are always inflated so when the settlement comes the providers get 20..50%. The crucial procedure is so called "medical coding" where medical notes (sometimes - scrawled on paper with a pencil) are being turned into bills - and that's where additional codes are getting added and more expensive codes are selected. There are books and guidelines on how to do the coding and some automated logic which "fixes" filled forms to bump the amounts a bit.

If the insurance (less frequently - the patient) pays more - that's just a bonus.

Billing itself gets a small fraction of the bill usually amounting to $20..50, they don't profit from inflated bills directly but the clients would select you on the basis of average settlements. Dispatchers also get little fractions. Things are very different when it comes to helicopter ambulances, where the bill could easily get to hundreds of thousands and everyone involved gets a lot. In fact, all the operators prefer to work with helicopters because of that, everyone involved references ground operations as "crap" or so.

Can't say for whole industry but that's what I've seen at one particular place working with several providers/dispatcher companies.

From what I can remember about the ground reality, a $12K bill would mean that they expected to actually get $3..4K. A typical ground bill for some particular region the company operated at was settled at $500..$2K while an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.

What are the margins on an ambulance ride?

Just a personal anecdote. I was living in China, my father was visiting and fell ill (anemia). We needed to go to the hospital and decided to call an ambulance vs. calling a car because it could enter the gated compound. For a 3 km ride the price difference wasn't even a concern. A car would cost ~$3 and an ambulance ended up about $30.

PS: An average net salary in that city was about $1700/month at the time.

I tell this story every time ambulance costs come up because it might be helpful to anyone. I once lived in San Francisco in the mid-2010s. In SF, the SFFD operates the vast majority of ambulances in the city. As in, 80%+. I once had the need to go to the hospital urgently and called 911. The ambulance that showed up was SFFD. They transported me and I recovered safely. I then got a bill from them saying that my insurance had refused to pay for it - apparently that insurance company (they're lucky I've forgotten which one, as naming and shaming health insurance people is one of my favorite hobbies) had refused to contract with SFFD, making them "out of network." Yes, an out of network ambulance. And remember, there's at least an 80% chance that an SFFD ambulance will show up, and I've never heard of them offering a menu of ambulance companies to the caller who's likely having a heart attack, bleeding, etc!

So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.

So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.

And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.

Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!

Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.

You don't have to pay them unless they're specific. I got a bill 3 years after being in an accident and I asked them for the documentation they legally have to provide me (itemization, the legal basis, detailed incident record, attempts on their part to contact insurance) of how they arrived at the sum. It's been a year since and they haven't given me anything.

Besides this kind of billing is banned in California now https://leginfo.legislature.ca.gov/faces/billHistoryClient.x...

The insurers just pay the in-network fee and you call it a day.

I spent a lot of time in healthcare finance and across most medical service industries the Medicare rate is actually not a loss. It’s a common thing said as it’s not super profitable, but it’s usually not a huge loss. It’s pretty close to what the cost of care should be. It just doesn’t give the extra padding for extremely fancy clinics, hospitals, admin and executive compensation, and often PE investor margin expectations. It’s usually slightly positive on contribution margin and given the volume of Medicare in the mix there’s enough flow through to cover reasonable overhead and perhaps slim margins. But, whenever I see a claim that the true cost of service is 10x over the Medicare rate, it’s a huge red flag there’s some financial shenanigans at play. Saying that Medicare is a loss, leaves the impression that it leaves a huge hole to fill so other payers need to pick up the bag in a huge way. This kind of lazy analysis blindly perpetuates this misconception. If they wanted to add value here, they should have performed a “what should an ambulance ride cost?” type analysis. You have to really strip out costs that are unneeded, excessive, and account for profit margin similarly. There’s no way $13k makes any sense for the service described. We need sensible cost controls in this industry. The industry hands these people blank checks when they can hide behind out of network, etc. It’s still captive price gouging.

Here in Australia, you can be 2,000km in the bush and an ambulance will fly out to you and fly you back to the city for free.

That being said, we also have private ambulance companies here that will sting you for a huge bill if you don't have private ambulance cover.

I live in Poland and despite being Europe from what I understand they don't have socialized healthcare. You need to buy insurance from the government, or private (I have both). If you don't have it, you don't have a right to healthcare.

Then, if you go to public doctors or hospital you still have to wait months for an exam or years for surgery. BUT, I've never heard of anyone going bankrupt from getting sick, or being scammed by their insurance not covering costs.

From what people make it sound, in the US you don't have socialized healthcare, getting doctors and exams is quick, but you also get scammed by insurance companies who will try their best to get out of paying, and I've definitely heard about people going bankrupt because they got sick.

Aside from the funding mechanism being a premium that everyone pays, the other part of the motivating story here that seems downright silly is:

- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.

- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.

Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".

We’re all pretending this is an unsolvable problem when really most of the world has solved it by making ambulance (EMS) funding similar to fire and police departments. Somehow in any emergency I’ve seen, all three show up, often EMS before police or fire dept, and somehow that’s a service that has to be supplemented by insurance billings.

The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.

It's simple. Ambs in the US are all private companies. Everywhere in the world private ambs are also extremely expensive and public ones free of charge. There is no truly public amb ride in the US.

I had to call an ambulance in Switzerland where ambulance prices are freely set by the operator (except in a few cantons which are enforcing reasonable flat rates)

A 5 minutes ride cost 1500.- (more or less the same in USD)

Because I had used a good broker to pick my insurance plan, I was left with “only” 500.- to pay out of pocket for the ride.

In Quebec, as a resident, going 3 blocks in the ambulance cost us about 500 CAD if I remember correctly.

> The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue. That’s how it’s done in the rest of the rich world. Some places, like the United Kingdom or Japan, simply fund ambulance services directly out of taxes; others, like the Australian state of Victoria, sell memberships in “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year per family.

So there is a solution.

I don't get this US medical system. And the more I get to read about it the less informed I feel. Sounds like every involved medical service out there is just to rip the patient off.

I called 911 last year when my wife was unresponsive in Maryland. At least 10 vehicles arrived in under 10 minutes. EMTs worked to revive her for 30 minutes doing what they described as the same care she would have received at the emergency room.

She was transported to the hospital because she had a slight heart beat. Had she been declared dead at home, police and other staff would have helped process the death report and application for death certificate. I did not receive a bill or provide insurance information.

Can anyone explain why coverage networks even exist? What exactly makes it so expensive for an insurance provider to deal with an out-of-network health care provider? That same health care provider would not be expensive for an in-network insurance provider. I have no sense whatsoever for why the same health care provider would be expensive in one case and inexpensive in another case.

Last year I had appendicitis in Italy, where I live. I called a cab to reach the nearest hospital, since I didn't feel so bad as warranting an ambulance. I got accepted, visited, transferred to the larger nearby hospital by ambulance, appendectomy, 4 nights stay, and I was provided with the drugs for the convalescence. When I was dismissed I took another cab back.

Total expense: ~25€ for the two taxi rides.

Very happy to pay my taxes, and very happy that when I don't need it myself, they go into financing the healthcare services for others that may or may not be able to pay out of pocket.

If there is no emergency way to contact an ambulance in network then there should be no in- or out-of-network.

Calling 911 does not give you an in-network and there no way to know in advance unless calling your insurance (in business hours, giving that you are not dying... which you probably are)

“ This time he didn’t have a choice. He was loaded into an ambulance for a six-mile transfer, evaluated without additional treatment, and sent home the same night.”

This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.

I think one of the most aggravating things about interacting with the health care system is losing control of cost/risk/reward tradeoffs. The mandatory transfer and ambulance ride in the linked story are an excellent example. I think I'd have walked out against medical advice in that circumstance, but there is the constant danger of being subjected to similar costs, both monetary and physical, when I am less conscious or at a serious informational disadvantage. The need to bring a patient advocate with you to the hospital whose role echoes both doctor and lawyer is becoming quite serious.

> There are parts of the U.S. that do this already. Ambulance rides are already subsidized by taxpayers in most places, thanks to public funding for fire departments; and a growing number of places have taken this further.

Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:

https://www.wake.gov/departments-government/emergency-medica...

So what is the practical advice to avoid high costs? Also for foreigners, long ago had a friend visit from Asia and wave away ambulance after a potential serious injury (waiver not to be transported) knowing of the high medical costs.

Uber for ambulances, got it. Claude, get to work. We will submit for Apple app review at EOD.

If you remove the $11,000 extortion “fee”, the remaining $1,000 is about the price found in the Western world countries.

Usually, when some system is getting outdated, the system gets replaced or updated to fit the needs. Does this system work for the majority of USA, or not? Do I read it correctly, that the poor people have medicare/medicaid and therefore it's fine for them, the average person has some health insurance and don't mind spending a few thousands of dollars once in a while when his life is in stake?

"On appeal, his insurance agreed to cover $9,967 of the charge—better than nothing, but it still left him on the hook for about $3,000."

Tell the insurance company to wait to release the funds until you talk to the ambulance company or to release the funds directly to you.

Tell the ambulance company they can take the $9,967 or get zero.

I worked in private equity in the 90's and looked at one of the big regional ambulance service companies that was up for auction. The underlying operating margins were fairly reasonable - the private equity owned companies only have issues because of their debt load.

In a market where competition isn't relevant, the price of things is whatever you can get someone to pay for it.

Anywhere else in the world it’s possible to do this orders of magnitude cheaper.

But yes, it’s because of “options” and not because of greed.

Some group of people tries to extract as much money as possible. You can call this capitalism. I think it’s a big scam.

Yet "the payment model is broken" and "some prices are absurd" can both be true

Its a collective emergency service, which can save lives.

If by law this service is required and you bill only the rides, you get this, high bills per ride.

It would be nice to see a chart of countries with cost of ambulance rides, cost for the patient and average response times.

Great article. One item that it avoids touching even though it clearly insinuates it - the solutions.

And among the solutions, there's one that is briefly alluded to, but skipped around like a hot potato.

What if EMS were to refuse services for those who don't pay for the option on a monthly basis? And for the rest, if they choose to pay "on the spot" they can be OON like everyone is now? Why give out a free (or subsidized) option out, at all ? After all, I dont think it is illegal to turn away Medicare & Medicaid patients if you are not in-network with them.

We pay for other types of insurance. EMS insurance seems like a natural fit for a family.

3rd world country.

Where I live (NJ) you don't pay if your picked up by a town run rescue squad. But you don't always know who's responding... Such a strange system.

Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.

> The standard answer is greed

The article is interesting, but it doesn't actually sufficiently dismiss this; it's the route cause of it all.

Why won't EMS providers strip down their services to the level where Medicare/Medicaid rates completely cover their costs?

I don't understand why taxes can be used to save property but not a person.

I was handling my moms bills when, at an independent living home, she was sent twice by ambulance for minor falls.

As the article says, thousands of dollars for these 5 minute drives.

(Fuck "credit score") I sent a check for $20 for each of the two bills. And I then did the same the next month when the bills came again.

I repeated this $20-a-month routine for a few years before, in both cases, they ended up closing the accounts-billing after perhaps $500 or so was paid.

Wait, being transported in an ambulance costs money? Man, every day I learn new things about how shitty the US health system is, and I'm more and more happy to not have to worry about deciding if I'd rather die or be broke in an emergency

Cost in Bulgaria: $0

Taxi / shuttle service also needs trained professionals, high fixed cost investment on specialized equipment, 24/7 availability.

I am shuttled to the airport at 4 am and paid $30.

It did not cost 20k per ride. So ambulance providers charge that much because they can. There is no real competition.

There should be an "Uberlance" - discount emergency pickups by Uber, at Uber prices.

> a car hit him; he did, in his words, “a little flip” over the vehicle, landed in the road

He was lucky he was hit by a car.

A slab fronted SUV or pickup would have dragged him underneath and so it goes.

Check your insurance to make sure you have transport. It's the same in Switzerland - it's an extra line on your insurance.

My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.

This is amazingly coherent and explanatory article!

the writer really went into depth about the problem and...surprise...the answer is almost embarrassingly simple.

Everyone in the country needs to read this.